A two-part Form HCFA-2654 (HCFA-2654A) (Hospital And Medical Insurance Termination
Notice) will be generated when premium HI and SMI are terminated because premiums
were not paid within the time limit set by the law. The Form HCFA-2654 will be sent
to the beneficiary and Form HCFA-2654A (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.