Social Security
Administration
Medicare
Prescription Drug Assistance
Acknowledgment
Notice
SDS
return address
Date: November 23, 2005
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
We have received your request for a review of your Application for Help with Medicare
Prescription Drug Plan Costs. We will review the file to be sure that a proper decision
was made. We will send you another notice as soon as the necessary work has been completed.
Providing Additional Information
If there is more information you want us to see, please send it to us within 10 days
from the date of this notice. You can mail the information to Social Security Administration,
(address
to be determined) or you can call us at (special
800#). If you need help, you should contact us immediately.
You May See The Information In Your File
If you wish to see the information in your file, you may do so before the date of
the review of your case. If you wish to review the file, please call us toll-free
at (phone number of SAU).
If You Have Any Questions
For information about Medicare prescription drug plans or other Medicare issues, visit
www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf
or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.
For information about the extra help with the costs related to Medicare prescription
drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 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.
We can answer most questions by phone.
If you do call, please have this letter with you. It will help us answer your questions.
Subsidy Determination Unit Manager