Basic (03-86)

DI 45001.087 Subsequent Determination of Deferred Decision, Approval of Earlier R-HI/ R-SMI Entitlement Based on Self-Dialysis Training

You were previously advised that we would notify you later if your medicare coverage could begin at an earlier date. It has been determined from the information given to the Social Security Administration about your training in self-care dialysis that you need not serve the qualifying period before your Medicare coverage based on kidney dialysis treatment can begin. Your entitlement to hospital insurance coverage has, therefore, been changed to begin          , and your entitlement to medical insurance coverage has been changed to begin          .

This notice replaces the information on the Medicare card (or notice) you previously received. A card will be mailed to you showing your new earlier Medicare effective dates. In the meantime, if you require hospital or medical services or there is a question raised about the coverage of your previous services, you may use this notice as proof of entitlement. Your old medicare card should be destroyed as soon as you receive a new one with the above dates of your coverage.

If you have any questions about your coverage or should your condition no longer require a regular course of dialysis treatment, please contact the people at any social security office.

If you believe this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request through any social security office. If additional evidence is available, you should submit it with your request.