BASIC (05-05)

A. Purpose/Use

The “Duplicate Subsidy Application from Third Party” notice is sent to the applicant when a subsequent application is received from a third party during the appeal period. The notice advises the applicant that SSA will not process the application from the third party. This notice is available on DPS.

B. Sample Notice for Duplicate Subsidy Application from Third Party

Social Security Administration

Medicare Prescription Drug Assistance

Important Information

Social Security Administration

Field Office Return Address

Date: November 1, 2005

                                                                 Social Security Number: 123-00-6789

JOHN Q. PUBLIC

123 MAIN ST

SPRINGFIELD OH 45501

We received an Application for Help With Medicare Prescription Drug Plan Costs filed on your behalf by (name of third party). Since we already processed an earlier application for you, we are taking no further action on this application.

If you disagree with the decision we made on your earlier application, you need to file an appeal. You may file an appeal by calling us toll-free at 1-800-772-1213.

For information about Medicare prescription drug plans or other Medicare issues, visit www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.

For information about the extra help with the costs related to Medicare prescription drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 1-800-772-1213. If you are deaf or hard of hearing, you may call our TTY number toll-free at 1-800-325-0778. We can answer most questions by phone.

If you do call, please have this letter with you. It will help us answer your questions.

                                                                                    Field Office Manager