The closeout notice is issued to the claimant.

EXCEPTION:

If the claimant’s personal representative establishes the protective filing and the claimant is a minor child under age 18 (i.e. an ESRD HI/SMI eligible child) or legally incompetent, issue the appropriate closeout notice to the personal representative. However, if the child is a proper applicant per GN 00204.003B.2.b, issue the closeout notice to the child.

All dates entered on closeout notices must be shown in the following format; e.g., April 5, 2006.

The employee preparing the closeout notice must sign the Manager's name at the end of the notice above the title, "Manager."

Manual notices containing protective filing closeout language should be prepared in DPS and a copy sent to the ORS. See SI 00601.040C.3 for additional instructions.

Annotate the eLAS worksheet or MAPS DW01 screen, as appropriate, when a manual subsidy protective filing notice is issued to closeout the protective filing. See SI 00601.037B.4. for the documentation procedures which are also applicable for the Title XVIII closeout issue.

Complete the SSA-L824-U2 as follows:

Identifying Information

Enter the addressee's name and address on the left.

Office Address: Enter the field office (FO) address.

Office Hours: Enter the hours the FO is open to the public.

Telephone Number: Enter the FO telephone number.

Date: Enter the date you give or mail the notice to the addressee.

Social Security Number (SSN): Enter the claimant's SSN.

First Paragraph

• •

  First fill-in:

  Enter: Date of interview

• •

  Second Fill-in:

  Enter: Choice 1: you

           Choice 2: inquirer’s name

• •

  Third Fill-in

  Enter: Choice 1: you are

           Choice 2: (claimant’s name) is

 

What Will Happen

• •

  First fill-in:

  Enter: mm/dd/yyyy (60 days after the date of the notice--must be a workday)

• •

  Second fill-in:

  Enter: mm/dd/yyyy (protective filing date)

• •

  Third fill-in:

  Enter: Choice 1- you (if the claimant established the protective filing)

  Choice 2 - inquirer’s name (if the claimant’s personal representative established the protective filing

 

If You Have Any Questions

First Fill in:

Enter: FO address

Complete the SSA-L825-U3 as follows:

Identifying Information

See HI 03010.030C.3 for completing the information at the top of the notice.

If a follow up copy must be issued per HI 03010.030C.1.c, enter the date it is issued after “Second Request Date."

First Paragraph

• •

  First fill-in

  Enter: mm/dd/yyyy (Date of Interview)

• •

  Second Fill-in

  Enter: Choice 1 - your (if the individual is the addressee)

  Choice 2- name of inquirer (possessive)

• •

  Third Fill-in

  Enter: Choice 1 – you are

              Choice 2 –he is

              Choice 3—she is

 

If We Do Not Hear From You

• •

  First Fill-in:

  Enter: mm/dd/yyyy (60 days after the date of the notice-must be a workday)

• •

  Second Fill-in

  Enter: mm/dd/yyyy (protective filing date)

 

If You Have Any Questions

Second Paragraph

• •

  First Fill-in:

  Enter: the contact person’s telephone number

• •

  Second Fill-in

  Enter: contact person’s name

• •

  Third Fill-in:

  Enter: Servicing FO address.

 

Social Security Administration

Medicare Prescription Drug Assistance

Important Information

 

 

 

On _______(1)_________, we talked with _________(2)_____ about your eligibility for extra help with Medicare prescription drug plan costs. Before we can decide if _________(3)______ eligible, you must file an application.

 

What To Do Next

 

You may complete an application right away on the Social Security Administration’s website at www.socialsecurity.gov on the Internet. If you would like a Social Security representative to take the application for you, call us toll free at 1-800-772-1213 to schedule an appointment.

 

What Will Happen

 

You should get in touch with us right away because the date you file an application can make a difference in when the extra help for Medicare prescription drug plan costs begins. If you file the application by ______(1)_________, we will use ____(2)__________, the date _________(3)_________ contacted us, as the filing date.

If you file an application, we will review the claim and make a decision. If you do not agree with what we decide, you will be able to appeal the decision.

 

If You Have Any Questions

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit, please have this letter with you. The address and telephone number of the office that serves your area is:

________________(1)______________

 

 

Also, if you plan to visit, you may call ahead to make an appointment. Our toll-free number is 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.

 

This will help us serve you more quickly when you arrive at the office.

 

 

 

Manager

 

SSA-L824-U2 (12-2004)

 

 

Social Security Administration

Medicare Prescription Drug Assistance

Important Information

 

 

On ______(1)__________, we talked with you about _______(2)__________ eligibility for extra help with Medicare prescription drug plan costs. We filled out the enclosed, “Application for Help with Medicare Prescription Drug Plan Costs”, based on your statements. However, we cannot decide if __________(3)________eligible until you sign the application and give us more information.

 

What You Need To Do

 

• •

  Answer any questions circled on the application

• •

  Correct any information that is wrong

• •

  Sign and date the application in the space called “Your Signature.” If your husband or wife is living with you, please have him or her sign in the space called “Your Spouse’s Signature”

• •

  Mail the application to us at the address shown above in the enclosed postage paid envelope

 

If We Do Not Hear From You

 

It is important that you sign the application and return it to us right away. Send it to us even if you do not have all the information. The sooner we get the signed application, the sooner we can decide if you are eligible for extra help with Medicare prescription drug plan costs. If we receive the signed application by __________(1)________, we will use _________(2)________, the date you contacted us, as the filing date.

 

What Will Happen

 

If you file an application, we will review the claim and make a decision. If you do not agree with what we decide, you will be able to appeal the decision.

 

If You Have Any Questions

 

For general questions about obtaining extra help for Medicare prescription drug plan costs, visit our website at www.socialsecurity.gov on the Internet. There you will also find the laws and regulations about the extra help.

 

For specific questions about your case, you may call ____(1)__________ and ask for _____(2)____________. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

____________(3)__________

 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

 

 

 

Manager

 

Enclosures

Application

Return Envelope

 

SSA-L825-U2 (12/2004)