NL 00722.027 Form CMS-1589 Medical Insurance Termination Notice
A. Sample Form
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A two-part Form CMS-1589 (CMS-1589A) (Medical Insurance Termination Notice) will be generated when SMI is terminated due to non-payment of premiums within the time limit set by the law. Form CMS-1589 will be sent to the beneficiary and Form CMS-1589A (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.