(If the individual is only eligible for HI or SMI, delete the inapplicable words)

District Office Address:       

Date:                          

Patient's Health   Insurance   

Claim Number               

Dear

Based on the information given to the Social Security Administration, you are (Mr./Ms.            is) eligible for hospital insurance beginning    (mo)        (yr.)    and for medical insurance beginning     (mo.)        (yr.)    . This notice will serve as evidence of your (his) eligibility for these benefits for 60 days from the date shown at the top of this notice unless you are notified otherwise during the 60-day period.

To obtain medical services (or reimbursement for medical services) before you receive a health insurance card, show this letter to your hospital or doctor but keep the letter with you. 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.

This letter should be destroyed as soon as you receive a health insurance card or other notice of eligibility.

Sincerely yours,               

Commissioner of Social Security

IMPORTANT

When services are provided on the basis of this notice, all bills or correspondence with an intermediary or the Social Security Administration should show the patient's health insurance claim number.