NL 00722.033 Form CMS-2687 Notice of Medicare Enrollment
A. Sample Form
Printer Friendly Version
A two-part Form CMS-2687 (CMS-2687A) (Notice of Medicare Enrollment) will be generated for insured beneficiaries in conditional pay status and uninsured cases when a premium HI or SMI election has been processed. The Form CMS-2687 will be sent to the beneficiary and Form CMS-2687A (not shown) will be filed on the left side of the folder for documentation.