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Cms L457 Form
Will end on (mm/dd/yyyy). You are responsible for all premiums due through the end of
that month. If you are currently billed for your medical insurance premiums, you should continue to promptly
pay all premiums due. A late payment could cause your insurance to stop earlier than you wish.
If you change your mind and decide you want to keep your Part B insurance, you can do so by completing the
form below. Take it or mail it to any Social Security office before the date your coverage will stop,...
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