BASIC (07-81)

NL 00722.023 Form CMS-L328 Notice of Termination of Medical Insurance Benefits

A. Sample Form

G-NL 00722.023A

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B. General

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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900722023
NL 00722.023 - Form CMS-L328 Notice of Termination of Medical Insurance Benefits - 05/12/2008
Batch run: 01/27/2009
Rev:05/12/2008