BASIC (07-81)

NL 00722.035 Form CMS-2688 Notice of Termination Of Hospital Insurance Benefits

A. Sample Form

G-HCFA-2688

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B. General

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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900722035
NL 00722.035 - Form CMS-2688 Notice of Termination Of Hospital Insurance Benefits - 05/08/2008
Batch run: 01/27/2009
Rev:05/08/2008