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Use this form: • If you have premium Part A or Part B, but wish to no longer be enrolled. • If you have Part B, but recently re-joined the workforce with access to employer-sponsored health insurance and wish to voluntarily terminate this coverage.
31 sty 2022 · Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance.
The completion of this form is needed to document your voluntary request for termination of Medicare coverage as permitted under the Code of Federal Regulations. 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.
Download a form CMS 1763 – click here. What do you use Medicare Form CMS 1763 for? This form is used to terminate the hospital and or medical insurance benefits you receive from Medicare.
The latest form for Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763) expires 2021-05-31 and can be found here. Office of Management and Budget control number searchable database.
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Complete form CMS-1763. •. Annotate “Beneficiary will be serving as an International Volunteer” on the CMS-1763 as the reason for the termination request. •. Mail form the CMS-1763 to the beneficiary with a courtesy return envelope to the WBDOC or instruct the person to mail the completed form to the follwing address:
