BASIC (07-81)

NL 00722.017 Form CMS-L325 Notice of Termination of Medical Insurance Benefits

A. Sample Form

G-NL 00722.017A

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B. General

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).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900722017
NL 00722.017 - Form CMS-L325 Notice of Termination of Medical Insurance Benefits - 05/12/2008
Batch run: 01/27/2009
Rev:05/12/2008