This is in regard to your application for medical insurance coverage.

An individual's entitlment to medical insurance benefits begins when he or she reaches age 65 or the 25th month of entitlement to disability benefits.

Approximately 3 months before you become eligible for Medicare coverage, we will send you further information regarding your effective date of entitlement to this protection and the amount of your monthly premium payments. Therefore, it will not be necessary for you to submit another application.

If you believe that 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 any such request through any Social Security office. If additional evidence is available, you should submit it with your request.

3901C

Exhibit NL 00703.604 is used to notify the beneficiary that he/she has applied for SMI prior to the beginning of his/her initial enrollment period. There are no fill-ins required.

Refer to NL 00703.005E. for 3901C text.

Information for this letter will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file.