NL 00722.031 Form HCFA-2654 Hospital and Medical Insurance Termination Notice
A. Sample Form
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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.