BASIC (03-86)

This is in reference to your entitlement to health insurance based on kidney disease. The law requires that Medicare health insurance based on kidney disease must end with the last day of the 12th month following the month in which the person ended a regular course of dialysis, unless before that date the patient receives a kidney transplant or begins a new course of dialysis. Since you ceased a regular course of dialysis in          , your Medicare will terminate on          , unless you or your treatment center submits evidence that you have begun a new course of dialysis or received a kidney transplant.

If you have begun a new course of dialysis or received a transplant, please have your treatment center complete the enclosed form CMS-2728-U3 and return it promptly (within 30 days) to the Social Security Administration in the envelope provided. If there is any additional information or evidence you want us to consider, please submit it without delay. You may submit it in writing, in person, or by telephone to a social security representative.

You will receive formal notice about termination of your Medicare health insurance. You will have an opportunity to file an appeal and to present further evidence at that time, if you do not agree with the decision.

If you have any questions about this notice, wish to submit additional evidence or have any difficulty in obtaining evidence regarding your transplant, please contact your local social security office as soon as possible. If you visit an office, please take this notice with you.

Enclosures:

Form CMS-2728-U3

Preaddressed envelope