TN 7 (07-95)
NL 00722.012 Form CMS-L1617-TR (Notice of Deletion from Part A State Buy-in or Part A Group Payer)
The Office of Systems prints and releases this notice to a Qualified Medicare Beneficiary (QMB) after the State deletes him from the Part A State buy-in or Part A Group Payer Account.
This notice tells the first month for which the beneficiary is liable for the Part A premium.
B. EXHIBIT — FORM HCFA-L1617-TR
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