Social Security Administration
Medicare Prescription Drug Assistance
Important Information
Date: December 10, 2005
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
On _______(1)_________, we talked with _________(2)_____ about ___3)_____ eligibility
for extra help with Medicare prescription drug plan costs. Before we can decide if
_________(4)______ eligible, you must file an application.
What To Do Next
You may complete an application right away on the Social Security Administration’s
website at www.socialsecurity.gov on the Internet. If you would like a Social Security representative to take the application
for you, call us toll free at 1-800-772-1213 to schedule an appointment.
What Will Happen
You should get in touch with us right away because the date you file an application
can make a difference in when the extra help for Medicare prescription drug plan costs
begins. If you file the application by ______(6)_________, we will use ____(7)__________,
the date _________(7)_________ contacted us, as the filing date.
If you file an application, we will review the claim and make a decision. If you do
not agree with what we decide, you will be able to appeal the decision.
If You Have Any Questions
If you have any questions, you may call, write, or visit any Social Security office.
If you call or visit, please have this letter with you. The address and telephone
number of the office that serves your area is:
________________(8)______________
Also, if you plan to visit, you may call ahead to make an appointment. Our toll-free
number is 1-800-772-1213. If you are deaf or hard of hearing, you may call our TTY
number toll-free at 1-800-325-0778.
This will help us serve you more quickly when you arrive at the office.
Manager
SSA-L824 (12/2004)
First Paragraph
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1)
Choice 1: Date of interview
Choice 2: Null
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2)
Choice 1: you
Choice 2: inquirer’s name
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3)
Choice 1: your
Choice 2: claimant’s name
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4)
Choice 1: you are
Choice 2: (claimant’s name) is
What to Do Next
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5)
Choice 1: 60 days after the date of the notice (mm/dd/yyyy-must be a workday)
Choice 2: Null
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6)
Choice 1: date of interview
Choice 2: Null
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7)
Choice 1: you
Choice 2: name of inquirer
If You Have Any Questions
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8)
Choice 1: FO address
Choice 2: Null