TN 30 (03-96)

Document Identifier for Word Processor: E3622

A. EXHIBIT LETTER

The law provides that an individual's disability shall end if his/her condition improves so that he/she becomes able to do substantial gainful work. The medical evidence in your case shows that your condition has so improved. Therefore, your entitlement to a disability-based benefit ends (1) .

Since you are no longer entitled to a disability-based benefit, your health insurance coverage also ends with the last day of (2) . The supplementary medical insurance premiums due through that month will be collected from your benefit payments.

The ending of your disability-based benefit entitlement and health insurance eligibility has no effect on your entitlement to (3) benefits.

If you believe that this determination is not correct, you may request that your claim 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 any such request through any Social Security office. If additional evidence is available, you should submit it with your request.

If You Have Any Questions

3901C

B. REQUESTING INSTRUCTIONS

This notice is used to notify a deemed DWB that entitlement to a disability-based benefit ended because the disabling condition improved and the beneficiary became able to do substantial gainful work.

Fill-ins:

1. month and year the disability ends

2. month and year Medicare coverage ends

3. type of benefit

Refer to NL 00703.005E for text of 3901C.

C. TYPING INSTRUCTIONS

Information for this notice will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP2 in file.