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This form is for people who want to end their Medicare Part A, Part B, or Part B immunosuppressive drug coverage. It explains the consequences, requirements, and procedures of disenrollment, and provides contact information for help and assistance.
31 sty 2022 · CMS 1763. Form Title. Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance. Revision Date. 2022-01-31. O.M.B. #. 0938-0025. O.M.B. Expiration Date. 2024-04-30.
You can voluntarily terminate your Medicare Part B (Medical Insurance). To find out more about how to terminate Medicare Part B or to schedule a personal interview, contact us at 1-800-772-1213 (TTY: 1-800-325-0778) or visit your nearest Social Security office.
1 sty 2006 · CMS Forms List. The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title. Showing 1 – 10 of 167 entries.
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.
Fill out Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance (Form CMS-1763) (PDF) and fax or mail it to your local Social Security office. You can cancel Part A only if you pay a premium for it.
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.
