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.