Basic (03-86)

DI 45001.094 R-HI Entitlement, R-SMI Refused (Temporary Notice)

Based on the information given to the Social Security Administration regarding your kidney condition, you are eligible for hospital insurance beginning          . Our records indicate that you did not elect supplementary medical insurance coverage.

This notice will serve as immediate evidence of your eligibility for hospital insurance 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 hospital services before you receive your health insurance card, show this letter to your hospital, 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. If you visit an office, please take this notice with you.