BASIC (07-81)

NL 00722.029 Form CMS-2653 Hospital Insurance Termination Notice

A. Sample Form

G-HCFA-2653

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B. General

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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900722029
NL 00722.029 - Form CMS-2653 Hospital Insurance Termination Notice - 05/08/2008
Batch run: 01/27/2009
Rev:05/08/2008