TN 68 (09-15)

NL 00703.621 R-HI/R-SMI — Award Based on Transplant or Dialysis, Entitlement Dates are the Same or Later Than D-HI/D-SMI Coverage (Conversion Notice)

Document Identifier for Word Processor: E3621

A. Requesting Instructions

This notice is used to notify a beneficiary already entitled to Medicare coverage under the disability provisions of the Act that he/she is also entitled to Medicare coverage based on chronic renal provisions.

B. Exhibit Letter

We have approved *F1 claim for Medicare benefits. *F2 based on *F3 need for kidney dialysis or kidney transplant.

3621A

*F1 *F2 Medicare because *F3 disability benefits. The starting *F4 for *F5 Medicare *F6 will not change.

OR

 

3621B

Since you are already entitled to Medicare based on your entitlement to monthly disability benefits, there will be no change in the effective date of your hospital insurance. However, you now have medical insurance beginning *F1 . Your monthly medical insurance premium is $ *F2 .

*F1 Medicare will continue as long as *F2 disability benefits. If *F3 disability benefits stop, *F4 Medicare may continue based on a kidney condition for up to:

  • 12 months after dialysis ends, or

  • 36 months after the last transplant.

Please report to us any major change in *F5 kidney condition or treatment.

Suspect Social Security Fraud? (CTDO)

Please visit http://oig.ssa.gov/r or call the Inspector General’s Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security.

If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-*F3-*F4-*F5. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You may also write or visit any Social Security office. The office that serves your area is located at:

*F6

*F7

*F8

*F9 *F10-*F11

  

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

C. Exhibit notice fill-ins

E3621.1 Fill-ins

*F1-1 Your

*F1-2 Beneficiary’s full name

  

*F2-1 You qualify

*F2-2 He qualifies

*F2-3 She qualifies

   

*F3-1 your

*F3-2 his

*F3-3 her

   

3621A Fill-ins

*F1-1 You

*F1-2 Beneficiary’s full name

   

*F2-1 already have

*F2-2 already has

   

*F3-1 you receive

*F3-2 he receives

*F3-3 she receives

*F4-1 date (select when person has only Part A)

*F4-2 dates (select when person has both Part A and Part B)

   

*F5-1 your

*F5-2 his

*F5-3 her

   

*F6-1 Part A (hospital insurance)

*F6-2 Part A (hospital insurance) and Part B (medical insurance)

   

3621B Fill-ins

*F1 date medical insurance begins

*F2 monthly medical insurance premiums

NOTE: Use 3621B if claimant is already entitled to D-HI only.

   

3621.2 Fill-ins

*F1-1 Your

*F1-2 Beneficiary’s full name

   

*F2-1 you receive

*F2-2 he receives

*F2-3 she receives

   

*F3-1 your

*F3-2 his

*F3-3 her

   

*F4-1 your

*F4-2 his

*F4-3 her

   

*F5-1 your

*F5-2 his

*F5-3 her

   

CTDO Fill-ins

*F1-1 Zip code

*F