NL 00701.117 Form CMS-L457 — Acknowledgement of Request for Medicare Part B Termination

A. Sample form

Select CMS-L457 to obtain a fillable form.

G-CMS-L457-1

 View PDF Version

G-CMS-L457-2

Printer Friendly Version

B. Purpose/Use

This notice is used to acknowledge receipt of the claimant's request for medical insurance termination.

C. Preparation of form

The source of information for completing this letter will be either the SSA-573 or SSA-559. There is only one fill-in in the notice:

  1. the date the medical insurance coverage will end.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701117
NL 00701.117 - Form CMS-L457 -- Acknowledgement of Request for Medicare Part B Termination - 04/24/2014
Batch run: 04/24/2014
Rev:04/24/2014