NL 00701.120 Form CMS-L458 — Acknowledgement of Request for Premium Hospital Insurance Termination

A. Sample Form

G-CMS-L458-1

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G-CMS-L458-2

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G-CMS-L458-3

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B. Purpose/Use

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

C. Preparation of form

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

  1. date hospital insurance will end


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701120
NL 00701.120 - Form CMS-L458 -- Acknowledgement of Request for Premium Hospital Insurance Termination - 05/31/2017
Batch run: 05/31/2017
Rev:05/31/2017