TN 92 (11-22)
Document Identifier for Word Processor: E4064
This letter is used when developing an incomplete Medicare enrollment or disenrollment request.
Universal Text Identifier (UTI) or Caption
Language
HIB319
We are writing to let you know we received (1) (2).
HIB320
We reviewed (1) form and the request (2). Please call Social Security to confirm your request. We cannot process your request until you contact us or submit a new request.
REFC01
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
REF196
Need More Help?
1. Visit www.ssa.gov for fast, simple, and secure online
service.
2. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm.
If you are deaf or hard of hearing, call TTY 1-800-325-0778.
Please mention this letter when you call.
3. You may also call your local office at (1).
(2)
(3)
(4)
(5)
(6)
(7)
How are we doing? Go to www.ssa.gov/feedback to tell us.
Fill-ins
your, or Beneficiary's name (possessive)
CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance) form
CMS-L564 Request for Employment Information form (or other evidence of GHP or LGHP coverage based on current employment status)
CMS-10797 Application for Medicare Part A and Part B – Special Enrollment Period (Exceptional Circumstances)
CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage form
CMS-4040 Request for Enrollment in Supplementary Medical Insurance form
request for enrollment
CMS-1763 Request for Termination of Premium Hospital and/or Supplementary Medical Insurance form
returned Medicare card
request for disenrollment
(blank for dictated fill-in)
was incomplete
was not signed
was missing accompanying Form CMS-L564 Request for Employment Information (or other evidence of GHP or LGHP coverage based on current employment status)
was missing accompanying Form CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance)
was missing supporting documentation of eligibility for the SEP (Exceptional Circumstances)
did not have the attestation completed
did not have the refusal box checked
was submitted a significant amount of months ago
Phone number
Address Line 1
Address Line 2
Address Line 3, or null
Address Line 4, or null
Address Line 5, or null
Address Line 6, or null