TN 30 (03-96)

NL 00703.625 Withdrawal From SMI — Entitlement to CHAMPUS or CHAMPVA

Document Identifier for Word Processor: E3625

A. EXHIBIT LETTER

This is in reference to your notice to us that you do not want to be enrolled in the medical insurance part of Medicare because you have coverage under (1) . You originally filed your refusal or withdrawal request on (2) .

Under (3) regulations, individuals regardless of their age, lose their (4) coverage when they become eligible for Medicare. So that you will not be left unprotected against the cost of medical care, we will take no action to cancel your medical insurance unless you notify us within 60 days after the date of this notice that you still do not want to be enrolled in the medical insurance part of Medicare.

If you still wish to cancel your medical insurance, sign the statement below and return this notice to us in the enclosed envelope. Upon receipt of your signed statement, we will take action to cancel your medical insurance.

If you have any questions in regard to Medicare, please get in touch with any Social Security office. If you call in person, please take this notice with you.

I understand that I do not have coverage under the (5) program because I am eligible for Medicare coverage. I still wish to cancel my medical insurance part of Medicare.

Signature  Date

 

Enclosure:

Envelope

B. REQUESTING INSTRUCTIONS

  • This notice will be used when a beneficiary indicates he/she is refusing or withdrawing from the Supplementary Medical Insurance program because of entitlement to the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) or to the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).

  • When applicable, attach the Medicare Card (HCFA-1966) to be returned to the beneficiary.

     

Fill-ins:

  1. “Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)” or “Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)”

  2. date of beneficiary's notice to us.

  3. “Department of Defense,” or “Department of Veterans Affairs”

  4. “CHAMPUS” or “CHAMPVA”

  5. “CHAMPUS” or “CHAMPVA”

C. TYPING INSTRUCTIONS

Information for this notice will be shown on Form SSA-573. The authorizer will furnish the fill-in information and when applicable, attach the beneficiary's Medicare card (Form HCFA-1966) to return to the beneficiary.

The typist should include a self-addressed envelope with the notice and the claim number should be typed on the inside of the envelope below the flap.

NOTE: The return envelope should be placed lengthwise on the left-hand side of the beneficiary notice and stapled in the upper left-hand corner.


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