- Form #
- CMS L458
- Form Title
- ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION
- Revision Date
- 02/01/2003
- O.M.B. #
- EXEMPT
- O.M.B. Expiration Date
- N/A
- CMS Manual
- N/A
- Special Instructions
- You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213
