NL 00722.029 Form CMS-2653 Hospital Insurance Termination Notice
A. Sample Form
Printer Friendly Version
A two part Form CMS-2653 (CMS-2653A) (Hospital Insurance Termination Notice) will be generated for all premium-HI terminations due to non-payment of premiums. The Form CMS-2653 will be sent to the beneficiary and the CMS-2653A (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.