BASIC (03-86)

Based on the information given to the Social Security Administration regarding your kidney condition, you are eligible for hospital insurance beginning          and for medical insurance beginning          . This medicare coverage is based upon the kidney transplant which you received in          . By law, Medicare coverage based on kidney disease ends with the last day of the 36th month after the month in which the transplant occurred or the last day of the 12th month after the month in which a regular course of dialysis ended, whichever is later. Your coverage will, therefore, end with the last day of          unless, by then, your condition has caused you to have a new transplant or to begin a regular course of dialysis treatment.

This notice will serve as immediate evidence of your eligibility for these benefits. When the permanent record of your claim has been established, you will receive your health insurance card and a formal notice which includes an explanation of your appeal rights. When you receive your health insurance card, you should use it instead of this letter and show it to hospital authorities or your physician whenever medical services are needed.

To obtain medical services (or reimbursement for medical services) before you receive your health insurance card, show this letter to your hospital or doctor but keep the letter with you. All bills or correspondence should show your health insurance claim number as shown above.

This temporary notice of eligibility is to be used only by the person to whom it is addressed. Misuse is unlawful and will make the offender liable to a penalty.

If you have any questions, please contact the people at any social security office. Please take this notice with you if you visit an office.