TN 30 (03-96)
NL 00703.628 Notice When Claimant Protests Termination
Document Identifier for Word Processor: E3628
A. EXHIBIT LETTER
The recent notice which we sent to you regarding the termination of your medical insurance was erroneous. Your medical insurance will be continued as long as you pay your premiums timely. You will soon receive a premium billing notice which will show the total premiums which are now due. The bill will show all months for which premiums should be paid and when such payments are due.
We sincerely regret any inconvenience we may have caused you.
B. REQUESTING INSTRUCTIONS
This notice will be used when a beneficiary inquires about the erroneous medical insurance termination.
C. TYPING INSTRUCTIONS
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. No fill-ins are required.