DBC035 (Optional if the beneficiary has a representative payee)
The information given in this notice concerns _1_.
You were recently notified that the last disability payment you are entitled to is
for the month of _2_.
Since you are no longer entitled to disability benefits, your hospital and medical
insurance coverage under Medicare ends the last of _3_.
Overpayment Information
Our records show you received $_4_ more in Social Security benefits than you should have. This happened because you
were paid benefits for _5_ months after _6_. The above amount includes medical insurance premiums of $_7_ which were withheld from your benefit check(s) for the same period.
How To Pay Us Back
You should refund the amount shown above within 30 days from the day you get this
letter. In addition, you should also include $_8_ to pay your medical insurance premiums due for _9_. Please make your check or money order payable to “Social Security Administration,
Claim No. _10_,” and send it to us in the enclosed envelope.
If You Disagree With This Decision
If you request a waiver or reconsideration within 30 days of the date of this notice,
you will not have to repay _11_ overpayment until a review of _12_ case is completed. The review is described in more detail on the attached Form SSA-3105,
Important Information About Your Appeal and Waiver Rights.
Please call, write, or visit any Social Security office if you want to request reconsideration
or if you believe you should not have to repay the overpayment and want to request
a waiver. The people there will be glad to help you complete the forms for reconsideration
(SSA-561-U2, Request for Reconsideration) and/or waiver (SSA-632-BK, Request for Waiver
of Overpayment Recovery or Change in Repayment Rate).
If You Again Become Disabled
If your condition again prevents you from doing substantial gainful work before age
65, you should get in touch with any Social Security office about filing a new application
for disability benefits. If you apply promptly and are again found entitled to disability
benefits, your benefit payments may start with the first full month in which you were
again disabled.
If You Are Now age 62 or Over
Retirement benefits are payable at a reduced rate as early as age 62. If _13_ _14_ age 62 or over, you may wish to ask the people in any Social Security office for
more details.
INFC08 (Optional if SNO002 is requested)
Things To Remember
SNO002 (Optional for SNO beneficiary)
We are sending you this letter in both a standard print version and _15_. You will
receive them in separate envelopes.
If You Have Any Questions
We invite you to visit our website at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you
may call us toll-free at 1-800-772-1213, or call your local Social Security office
at _16_. We can answer most questions over the phone. If you are deaf or hard of hearing,
you may call our TTY number, 1-800-325-0778. You can also write or visit any Social
Security office. The office that serves your area is located at:
_17_
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.
Enclosures:
SSA-3105
Refund Envelope
Fill-ins:
-
1.
(DBC035 if required) Beneficiary’s name
-
2.
MM/YYYY last month benefits are due
-
3.
MM/YYYY last month when the beneficiary is entitled to Medicare
-
-
5.
Number of months the beneficiary is overpaid
-
6.
MM/YYYY last month benefits are due
-
7.
Amount of Medicare insurance premiums included in the overpayment
-
8.
Amount of Medicare insurance premiums
-
9.
MM/YYYY last month that Medicare insurance premiums are due
-
10.
Claim Number including BIC
-
11.
Beneficiary’s full name/your
-
12.
Beneficiary’s full name/your
-
13.
you/the children/Beneficiary’s full name
-
-
15.
(SNO002 if required) in a Braille version/on a compact disc in Microsoft Word format/on
an audio compact disc/a large print version
-
-
17.
FO street address, city, State, and ZIP code