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