Basic (03-86)

DI 45001.096 R-HI/R-SMI Entitlement Based on Transplant, Closed Period

Based on your kidney transplant, you are entitled to hospital insurance beginning          and medical insurance beginning          . Under the law, Medical coverage based on a kidney transplant ends with the last day of the 36th month after the month in which a kidney transplant is received, unless before that date a course of dialysis has begun or another transplant is received. Since you received a transplant in          and you have not subsequently received regular dialysis or another transplant, your Medicare coverage ends          .

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.

If you have any questions about your Medicare coverage, you should contact any social security office. If you visit an office, please take this notice with you.

Enclosure: HCFA-10128