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.