NL 00722.017 Form CMS-L325 Notice of Termination of Medical Insurance Benefits
A. Sample Form
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A two-part Form CMS-L325 (CMS-L325A) (Notice of Termination of Medical Insurance Benefits) will be generated for insured beneficiaries in current pay status who have requested termination of medical insurance coverage. The Form CMS-L325 will be sent to the beneficiary and Form CMS-L325A (not shown) will be filed on the left side of the folder for documentation. The form is printed and released from the program service centers.
NOTE: INTPSC see Form CMS-L327 (CMS-L327A).