NL 00722.025 Form CMS-1585 Notice of Medical Insurance Enrollment and Premium Deduction
A. Sample Form
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A two-part Form CMS-1585 (CMS-1585A) (Notice of Medical Insurance Enrollment and Premium Deduction) will be produced for processed “YES” election cases for the purpose of documenting the folder and providing a notice to the beneficiary regarding action taken as a result of a “YES” election. This form will be generated for current pay insured cases. The Form CMS-1585 is sent to the beneficiary and Form CMS-L1585A (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.