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.
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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:
the date the medical insurance coverage will end.