Your claim to establish eligibility for health insurance coverage under title XVIII of the Social Security Act as a disabled individual has been approved. Your health insurance coverage begins in (1) . A health insurance identification card will be mailed to you in or before that month.

Although you have been found entitled to a disability-based benefit, it is for the purposes of health insurance coverage only. It has no effect on the benefit to which you are now entitled.

3619A

 

OR

3619B

 

OR

3619C

The enclosed booklet lists the events you must report to the Social Security Administration as a disabled individual.

If you believe that this determination is not correct, you may request that your claim be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make any such request through any Social Security office. If additional evidence is available, you should submit it with your request. Keep this notice as a permanent record with the Social Security Award Certificate you received previously.

 

If You Have Any Questions

3901C

 

Enclosure:

SSA Pub. No. 73-10153

This notice is used when a beneficiary entitled to mother's or widow's benefits files to establish a disability for health insurance coverage purposes. This exhibit should be used to report the date of entitlement to disability (DOED).

 

Fill-in:

1. (1) 

   the month and year the health insurance coverage begins

Include 3619A in Medical Improvement Possible Cases

Include 3619B in Medical Improvement Not Expected Cases

Include 3619C in Medical Improvement Expected Cases

Refer to NL 00703.619 for 3619A, 3619B, and 3619C text and fill-in.

Refer to NL 00703.005E. for 3901C text.

Information for this notice will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file.