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Form CMS-1763, also known as “Request for Termination of Premium Hospital and/or Supplementary Medical Insurance,” is used by individuals who wish to voluntarily terminate their Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance). This form is crucial for those who, for various reasons, decide that they no longer want to continue their coverage under these parts of Medicare. The termination of Medicare benefits is a significant decision that requires the completion and submission of CMS-1763 to ensure that the request is processed correctly and that the individual understands the implications of terminating their Medicare coverage.
The process for using CMS-1763 involves contacting the Social Security Administration (SSA) to set up an interview, during which the form is completed. This interview can be conducted either in person at an SSA office or over the phone. The purpose of the interview and the form is to ensure that the individual fully understands the consequences of discontinuing their Medicare coverage, such as potential gaps in health insurance and the need for alternative coverage.
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What it is: Form CMS-1763 is a Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID); use this form to request to end your Medicare coverage.
Who signs: Sign in the Signature box and enter the Date signed (mm/dd/yyyy).
Enter the Enrollee first name, Middle name, Last name and Suffix.
Enter the Medicare Number.
Enter the Mailing address, City, State and ZIP code.
Enter the Phone number and Email address.
Enter the Name of person completing this form if not the enrollee.
Check the box for the part you request to end: Part A (Hospital Insurance), Part B (Medical Insurance) or Part B-ID.
You can terminate Part A only if you pay a premium for it.
You can terminate Part B or Part B-ID at any time.
Ending Part B will also terminate your Part A if you pay a premium for Part A.
Enter the month and year you want coverage to end.
Your Part B-ID coverage will end the last day of the month you request.
For example, if you ask for coverage to end in April, your last day of coverage will be April 30.
Your Part A/Part B coverage will end the last day of the month AFTER the month you submit your request.
For example, if you submit your request April 5, your coverage will end May 31.
Entering the reasons you want to end your Medicare coverage is optional.
Sign in the Signature box and enter the Date signed (mm/dd/yyyy).
If this form has been signed by mark (X), a witness who knows the person applying must also sign in the witness box.
Enter the Name of witness (first and last name).
The witness signs in the Signature of witness box and enters the Date signed (mm/dd/yyyy).
Section 1838(b) and 1818A(c)(2)(B) of the Social Security Act require filing of notice advising the Administration when termination of Medicare coverage is requested.
The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you change your mind about ending your coverage, you must contact SSA before your coverage end date.
On page 2 of CMS-1763 (01/26), submit your form by mail or fax: mail or fax your completed, signed form to your local Social Security office. Find an office near you at SSA.gov/locator.
[1] Form CMS-1763 (01/26), Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID), Centers for Medicare & Medicaid Services (the Official source link on this page).