TN 31 (02-97)

NL 00703.629 General “Check Box” Notice

 

Document Identifier for Word Processor: E3629

A. EXHIBIT LETTER

This refers to your inquiry about your medical insurance. The block(s) checked below is in reply to your question.

(Optional)  
3629AWe have taken action to credit your record with the premium payments you have made to date. Our records indicate your medical insurance premiums have been paid through (1) .
(Optional)  
3629BPlease disregard the notice of premiums due if you have already sent in your payment. The time needed to enter payments may have delayed our crediting your record. We regret any inconvenience caused you.
(Optional)  
3629CThe notice advising you of the termination of your medical insurance was incorrect. Action is now being taken to correct your records, but you may continue to use the health card issued to you.

  (1)  

 

We are using this type of letter only to enable us to reply to your inquiry promptly. If you have any further questions about your medical insurance, please visit or telephone any Social Security office.

B. REQUESTING INSTRUCTIONS

This notice will be used when a beneficiary inquires about his/her medical insurance. Select the appropriate paragraph or provide a dictated paragraph.

 

Fill-in:

  1. dictated explanation, if necessary

3629A:

  1. Month and Year

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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703629
NL 00703.629 - General "Check Box" Notice - 02/13/1997
Batch run: 01/27/2009
Rev:02/13/1997