| Assigned Number | Title | Release Date Sort ascending | File Type | Language | Available to Order |
|---|---|---|---|---|---|
| F-01283L | Notification of Non-Covered Benefit Letter Template - Model, Laotian | 12/01/2022 | Word | Laotian | No |
| F-01283S | Notification of Non-Covered Benefit Letter Template - Model, Spanish | 12/01/2022 | Word | Spanish | No |
| F-01283SE | Notification of Non-Covered Benefit Letter Template - Model, Serbo-Croatian | 12/01/2022 | Word | Serbian (Serbo-Croatian) | No |
| F-01283AR | Notification of Non-Covered Benefit Letter Template - Model, Arabic | 12/01/2022 | Word | Arabic | No |
| F-01283CM | Notification of Non-Covered Benefit Letter Template - Model, Chinese (Simplified) | 12/01/2022 | Word | Chinese (Simplified) | No |
| F-01283SO | Notification of Non-Covered Benefit Letter Template - Model, Somali | 12/01/2022 | Word | Somali | No |
| F-01283H | Notification of Non-Covered Benefit Letter Template - Model, Hmong | 12/01/2022 | Word | Hmong | No |
| F-01283 | Notification of Non-Covered Benefit Letter Template - Model | 12/01/2022 | Word | English | No |
Last revised July 5, 2025