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)

A. POLICY

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

 

G-HCFA-L1617-TR

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900722012
NL 00722.012 - Form CMS-L1617-TR (Notice of Deletion from Part A State Buy-in or Part A Group Payer) - 05/08/2008
Batch run: 01/27/2009
Rev:05/08/2008