*        ^5SS?_ DEPARTMENT OF
hi   }th, education, and welfare   )
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»^Bs«a^« Social. Security Administration
YOUR RECORD OF HOSPITAL INSURANCE
BENEFITS USED UNDER MEDICARE
(THIS IS NOT A BILL)
i~ SGC".   HYUf' ~~1
933    lALrN-.-H   i'iV DATE:       2-12-68
LOS    V'-iGcL.S   f . 90026
YOUR CLAIM NUMBER:  i>7_—24-94354
I   I In any correspondence, please refer to this number.
Dear Beneficiary:
Recently, your Medicare Hospital Insurance helped pay for the services described below.  We are pleased that
your social security program was able to assist you.
1.  OUR RECORDS SHOW THAT YOU RECEIVED THESE SERVICES
SERVICES WERE PROVIDED BY TYPE OF SERVICES WHEN
TEMPLE   HOSP                                                                             INPATIENT 8-31-67
235   N   HOOVER   ST                                                                  HOSPITAL T0                          I
LOS   ANGELES   CALIFORNIA   90004 9-08-67
Your Medicare Hospital Insurance has paid the cost of all COVERED SERVICES except:
440.00 FUR THE *40 INPATIENT DEDUCTIBLE.
.
)
) For information about any services NOT COVERED by your Medicare Hospital Insurance, please see other side.
HOSPITAL SEKV Of SOUTHERN CALIFORNIA
_. . . . .      k nuor i i ml    jLf^v    ur
If you have any questions about this   ^        A7 77    <UJjMr£T   P«J VH
record, please get in touch with: f       L0S   &NGELES   CALIFORNIA   90027
2.  OUR RECORDS NOW SHOW THESE BENEFIT TOTALS
| AVAILABLE TO USE FOR
THIS "SPELL OF ILLNESS"
USED THIS TIME TOTAL USED (See "D" on other side.)
INPATIENT HOSPITAL DAYS B * #_
EXTENDED CARE FACILITY DAYS NONE *  *
HOME HEALTH VISITS NONE
bEGINMi\<7   V.ITH   J,.\J."FY   lf    19o6»    YOU   ALSO   BECAME   ENTITLED   TO   A   LIFETIME
KtSc^VE   OF   oO    nPiTIF'JT   h'JSPIT'L   CAYS.
*   UNABLE   TC   FuKJISH   Sin:   /-   P*M'JR   CLUV   IS   STILL   BEING   PROCESSED,
►    If you again use services which are covered by your Medicare Hospital Insurance, please show this Record
and your Health Insurance Card to the organization providing services.
SEE OTHER SIDE FOR ADDITIONAL INFORMATION.
Sincerely yours,
XJ bincerely yours,
//Act 4f Aa,
Robert M: Ball
Commissioner of Social Security
* FORM    SSA-1533    t8-67)