TN 5 (08-92)

NL 00722.037 Forms CMS-L623 Notice Regarding Collection of Medical Premiums

A. SAMPLE FORM

G-NL 00722.037A

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B. GENERAL

A two-part Form CMS-L623 (CMS-L623A) (Notice Regarding Collection of Medical Premiums) will be generated when medical jurisdiction is transferred from the Social Security Administration to the Railroad Retirement Board. The Form CMS-L623 is sent to the beneficiary and Form CMS-L623A (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/0900722037
NL 00722.037 - Forms CMS-L623 Notice Regarding Collection of Medical Premiums - 05/12/2008
Batch run: 01/27/2009
Rev:05/12/2008