BASIC (03-86)

Based on the additional information provided to us regarding your kidney transplant, we have determined that your Medicare coverage should begin at an earlier date. Therefore, your coverage has been changed to begin          for hospital insurance and          for medical insurance.

Since Medicare coverage based on a kidney transplant ends with the last day of the 36th month after the month in which the transplant occurred, your coverage will end          unless you have a new transplant or begin a regular course of dialysis treatment. We will contact you shortly before the 36th month for information about your condition at that time.

This notice replaces the information on the Medicare card (or notice) you previously received. A card will be mailed to you showing your new earlier Medicare effective dates. In the meantime, if you require hospital or medical services or there is a question raised about the coverage of your previous services, you may use this notice as proof of entitlement. Your old Medicare card should be destroyed as soon as you receive a new one with the above dates of your coverage.

If you believe 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 your request through any social security office. If additional evidence is available, you should submit it with your request.

If you have any questions about your Medicare coverage, you should contact any social security office. If you visit an office, please take this notice with you.