Office of Disability and International Operations
1500 Woodlawn Drive
Baltimore, Maryland 21241-0001
NOTICE OF MEDICAL INSURANCE ENROLLMENT AND PREMIUM DEDUCTION
3801 CONNECTICUT AVE
WASHINGTON DC 20008
Claim No. xxx-xx-xxxx A
This is in reference to your enrollment in the medical insurance part of Medicare. A red, white, and blue health insurance card showing the date your coverage begins for both hospital and medical insurance protection has been mailed to you.
The premium for your medical insurance is deducted from benefits when possible. The information below shows how your payment has been adjusted to collect these premiums.
Coverage begins: APR 1994
Monthly Premium: $41.10
Premium Amount Deducted: $41.10
This Pays For The Month(s) of: APR 1994
Your Next Payment Will Be Received Shortly After: APR 02, 1994
Amount of Your Next Payment: $811.00
Old Monthly Payment Amount: $852.00
New Monthly Payment Amount: $811.00
If you have any questions about your benefits or Medicare coverage, or if you have not previously received your health insurance card and do not receive one within 4 weeks after the receipt of this notice, please get in touch with any social security office. If you visit an office, please bring this letter. It will help us answer your questions.
Department of Health and Human Services
Health Care Financing Administration
Form HCFA-1585 (10-87)