Basic (03-86)
DI 45001.079 R-HI/R-SMI Award Based on Kidney Dialysis—No Participation in Self-Dialysis Training
(Temporary Notice)
Based on the information given to the Social Security Administration regarding your
kidney condition, you are eligible for hospital insurance beginning and for medical insurance beginning . By law, Medicare coverage based on kidney disease ends with the last day of the
12th month after the month in which a course of dialysis treatment is ended unless
you resume dialysis or receive a kidney transplant before that date. In the event
of a transplant, coverage ends with the last day of the 36th month after the month
in which the transplant occurs.
This notice will serve as immediate evidence of your eligibility for these benefits.
When the permanent record of your claim has been established, you will receive your
health insurance card and a formal notice which includes an explanation of your appeal
rights. When you receive your health insurance card, you should use it instead of
this letter and show it to hospital authorities or your physician whenever medical
services are needed.
To obtain medical services (or reimbursement for medical services) before you receive
your health insurance card, show this letter to your hospital or doctor but keep the
letter with you. All bills or correspondence should show your health insurance claim
number as shown above.
This temporary notice of eligibility is to be used only by the person to whom it is
addressed. Misuse is unlawful and will make the offender liable to a penalty.
If you have any questions, please contact the people at any social security office.
Please take this notice with you if you visit an office.