Skip to Main Content
Form #
CMS L457
Form Title
ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL 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
.