Basic (03-86)

DI 45001.097 R-HI/R-SMI Entitlement Based on Dialysis, Closed Period

Based on the course of dialysis you received for your kidney condition, you are entitled to hospital insurance beginning          and medical insurance beginning          . Under the law, Medicare coverage based on dialysis ends with the last day of the 12th month after the month in which the course of dialysis was discontinued unless dialysis is resumed or a transplant is received before that date. Since your course of dialysis was discontinued in          , 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 this 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