NL 00722.023 Form CMS-L328 Notice of Termination of Medical Insurance Benefits
A. Sample Form
Printer Friendly Version
This two-part Form CMS-L328 (CMS-L328A) (Notice of Termination of Medical Insurance Benefits) will be generated for INTPSC when insured beneficiaries in suspense status or uninsured beneficiaries request termination of medical insurance coverage. The Form CMS-L328 will be sent to the beneficiary and Form CMS-L328A (not shown) will be filed on the left side of the folder for documentation. The form is printed and released from INTPSC.
NOTE: All other program service centers and ODO see Form CMS-L326.