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Notification of Non-Covered Benefit Letter Template - Model

Assigned number Title Release date File type Language Available to order
F-01283 Notification of Non-Covered Benefit Letter Template - Model 12/01/2022 Word English 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-01283H Notification of Non-Covered Benefit Letter Template - Model, Hmong 12/01/2022 Word Hmong No
F-01283L Notification of Non-Covered Benefit Letter Template - Model, Laotian 12/01/2022 Word Lao No
F-01283SE Notification of Non-Covered Benefit Letter Template - Model, Serbo-Croatian 12/01/2022 Word Serbo-Croatian No
F-01283SO Notification of Non-Covered Benefit Letter Template - Model, Somali 12/01/2022 Word Somali No
F-01283S Notification of Non-Covered Benefit Letter Template - Model, Spanish 12/01/2022 Word Spanish No

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Last revised February 5, 2026