A two-part Form CMS-2688 (CMS-2688A) (Notice of Termination of Hospital Insurance
Benefits) will be generated for an enrollee who is terminating premium-HI coverage.
The CMS-2688 will be sent to the beneficiary and Form CMS-2688A (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.