NL 00722.019 Form CMS-L326 Notice of Termination of Medical Insurance Benefits
A. Sample Form
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A two-part Form CMS-L326 (CMS-L326A) (Notice of Termination of Medical Insurance Benefits) will be generated for insured beneficiaries in suspense status or for uninsured beneficiaries who have requested termination of medical insurance coverage. The Form CMS-L326 will be sent to the beneficiary and Form CMS-L326A (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-L328 (CMS-L328A).