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DEPARTMENT OF
JULTH, EDUCATION, AND WELFAI
,     wsM^vy Social Security Administration
I
YOUR RECORD OF HOSPITAL INSURANCE
BENEFITS USED UNDER MEDICARE
(THIS IS NOT A BILL)
)
r~ THE   ESTATE  OF ~I
scon hyun date:   io-n-68 l
933 MALTMAN AV
LOS   ANGELES   CA 90026 YOUR CLAIM NUMBER: A
I   I In any correspondence, please refer to this number.
Dear Beneficiary: J
Recently, your Medicare Hospital Insurance helped pay for the services described below.   We are pleased that
r your social security program was able to assist you. f
>        1.  OUR RECORDS SHOW THAT YOU RECEIVED THESE SERVICES     »
SERVICES WERE PROVIDED BY TYPE OF SERVICES WHEN
TEHPLE   HOSP                                                                            INPATIENT 12-19-6 7 ?     '
235   N   HOOVER   ST                                                                 HOSPITAL T0 |
LOS   ANGELES   CALIFORNIA  90004 1-17-68 5
Your Medicare Hospital Insurance has paid the cost of all COVERED SERVICES except: 5     '
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$40.00   FOP   THE   $40   INPATIENT   DEDUCTIBLE. {
$   32.00   FOR   THE  COST   OF   2   PINTS  OF   UNREPLACED   BLOOD. I     }
!>
) For information about any services NOT COVERED by your Medicare Hospital Insurance, please see other side. )
^   HOSPITAL SEP.V OF SOUTH FR.' C-* LIFC».!!.■
If you have any questions about this   _ _
1 1^ m^      hill  SUNSET   BLVD
) record, please get in touch with: r ^   ^^   CALIFnRNIA   90027
2.  OUR RECORDS NOW SHOW THESE BENEFIT TOTALS
1 AVAILABLE TO USE FOR
THIS "SPELL OF ILLNESS"
USED THIS TIME TOTAL USED (See "D" on other side.)
INPATIENT HOSPITAL DAYS	
EXTENDED CARE FACILITY DAYS_
HOME HEALTH VISITS
>
)
)
►    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,
sp sincerely yours,
fuUcf*/ A<Uls
Robert M. Ball
Commissioner of Social Security
FORM    SSA-1533    (8-67)