TN 5 (08-92)
NL 00722.037 Forms CMS-L623 Notice Regarding Collection of Medical Premiums
A. SAMPLE FORM
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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.