This letter is used when COLA or No COLA applies, a premium arrearage balance from the prior year(s) exists, and the prior year(s) balance is equal to or more than three months premiums at the standard rate. See HI 01001.041B.3.c.

LIS004	We are writing to give you new information about the (1) benefits which (2) on this Social Security record.
CHKC09	Your Benefits
CHK084	(1) monthly benefit amount is $(2) effective (3) and (4) monthly Medicare medical insurance premium is $(5).
HIBC01	Information About Medicare
HIB705	Since (1) monthly benefit amount is less than (2) Medicare premium, we will withhold (3) monthly benefits to pay part of (4) medical insurance premium. The difference between the premiums (5) for (6) and (7) monthly benefit amount for (8) is $(9). After adjusting (10) benefits, (11) $(12) in Medicare premiums. We enclosed a bill for that amount and a return envelope. In addition, our records show (13) past due medical insurance premiums of $(14) for (15). (16) must pay this medical insurance premium balance within 3 months of the date of this notice. A separate bill is enclosed for these past-due premiums. If the premium balance is not paid in full, (17) Medicare Part B coverage will stop the last day of (18).
CTDO	Suspect Social Security Fraud? Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101). If You Have 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 1-(3)-(4)-(5). 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: (6) (7) (8) (9)(10)-(11) 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.
HBN001	MEDICARE PREMIUM BILL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)     BILLING DATE: (1)   MEDICAL PREMIUMS FOR PERIOD ENDING: (2)   CURRENT AMOUNT DUE: (3)   PAYMENT DUE BY: (4)   • Return the bottom portion of this notice with your payment and use the enclosed envelope to mail your payment. • You must pay by check or money order. Include your Medicare number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE. • If you have changed your address, be sure to write your new address in the space provided below. • If you have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.   PLEASE DETACH AT DOTTED LINE ---------------------------------------------------------------- CMS-500A   Medicare Number: (5) Amount Due: $(6) Name: (7)   Make Checks Payable To: CMS MEDICARE INSURANCE   Send To: Medicare Premium Collection Center P.O. Box 790355 St. Louis, MO 63179-0355     ( ) Check here if your address has changed. Show new address below. ________________________________________ ________________________________________   PAYMENTS BY CHECK When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.
HBN001	MEDICARE PREMIUM BILL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)     BILLING DATE: (1)   MEDICAL PREMIUMS FOR PERIOD ENDING: (2)   CURRENT AMOUNT DUE: (3)   PAYMENT DUE BY: (4)   • Return the bottom portion of this notice with your payment and use the enclosed envelope to mail your payment. • You must pay by check or money order. Include your Medicare number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE. • If you have changed your address, be sure to write your new address in the space provided below. • If you have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.   PLEASE DETACH AT DOTTED LINE ---------------------------------------------------------------- CMS-500A   Medicare Number: (5) Amount Due: $(6) Name: (7)   Make Checks Payable To: CMS MEDICARE INSURANCE   Send To: Medicare Premium Collection Center P.O. Box 790355 St. Louis, MO 63179-0355   ( ) Check here if your address has changed. Show new address below. ________________________________________ ________________________________________   PAYMENTS BY CHECK When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.