Form CMS-1763

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Form CMS-1763

Health insurance has never been inexpensive in the United States. A special program — Medicare — has been developed and presented to the public so that all US citizens could feel safe and protected and understand that they will get the necessary help once they need professional medical assistance. However, due to various reasons, an individual might decide to terminate their premium hospital treatment coverage. Form CMS-1763 must be completed in this case to prove to the medical personnel that the patient has made this decision willfully and voluntarily and is fully aware of all the consequences. According to statistics, about 14,000 citizens initiate this form completion.

A person who has expressed a wish to stop their Medicare coverage will be accountable for paying for their hospital insurance. The form cannot be completed by CMS staff.

The information you are submitting in the paper is confidential. You may ask for a copy of this document for personal records. The use of this form does not involve small businesses.

According to the Social Security Act at Section 1838 (b) (1) (Attachment 1) and Section 1818A (c) (2) (B) (Attachment 2) and the Code of Federal Regulations at 42 CFR Section 406.28 (a) (Attachment 3) and Section 407.27 (c) (Attachment 4), an enrollee has to create a written document to confirm that they wish to terminate their insurance. The document compilation is important as, with its help, both the patient and the medical staff can be sure they will avoid unwanted legal arguments in the future. No sensitive questions are presented in the form.

Parts of the Document

The form is relatively simple to fill out. It consists of the following sections:

  • Enrollee’s name (or a legal representative);
  • Medicare number;
  • Dates your insurance will end;
  • Exact reasons for the termination;
  • Your essential personal data;
  • Enrollee’s signature;
  • Witnesses’ info.

Other CMS Forms

Take a look at a few other CMS PDFs accessible for editing with our editor. Besides that, remember that you can actually upload, fill out, and edit any PDF form at FormsPal.

How to Fill Out the Form

You will need to provide an original signature, while other sections of this paper might be completed electronically. To obtain a customized PDF document, we suggest you use our form-building software.

  • Provide Your Name

A full name (including your middle initial) has to be printed (or put in handwriting) herein.

step 1 provide your name filling out a form cms 1763

  • Enter Medicare Number

Each enrollee possesses a personal Medicare number that allows the Department of Health and Human Services to identify them. Input yours in this box.

step 2 enter medicare number filling out a form cms 1763

  • Indicate the Representative

If you have decided to complete this paper with the assistance of a designated attorney or legal representative of the enrollee, please indicate their name.

step 3 indicate the representative filling out a form cms 1763

  • Specify Your Request

You may choose to terminate hospital insurance, medical insurance, or both. Check the corresponding box.

step 4 specify your request filling out a form cms 1763

  • Provide the Dates Info

An enrollee has to insert the date when they expect their insurance to end.

step 5 provide the dates info filling out a form cms 1763

  • Describe the Reasons

The CMS and SSA need to understand why exactly you have opted for terminating Medicare coverage. So, if that is your case, make sure to provide lawful reasoning.

step 6 describe the reasons filling out a form cms 1763

  • Input Personal Info

Review the data you have submitted and append your signature. Write in ink. Do not forget to insert your complete residential address (including house number, street, city, state, and zip code), the date you are signing the paper on, and a phone number below.

step 7 input personal info filling out a form cms 1763

  • Witness the Form

In case an enrollee has signed the form with an “X,” this document will not be considered effective unless witnessed by two competent adults. They must provide their full names, along with the mailing addresses (including house number, street, city, state, and zip code).

step 8 witness the form filling out a form cms 1763