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Over ------------------------------------------------------------------------------------------------------------------------------I would like to keep my Medicare Part B insurance coverage. PRINT NAME Signature by mark must be witnessed below SIGN HERE Your Mailing Address City Telephone Number State Signature of Witness necessary if you sign by mark FORM CMS-L457 03/10 Social Security Number Zip Code Address of Witness DESTROY PRIOR EDITIONS pr.

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Generally, you won't have to pay a Part B penalty if you qualify for a Special Enrollment Period. Learn more about Special Enrollment Periods. You'll pay an extra 10% for each year you could have signed up for Part B, but didn't. You may also pay a higher premium depending on your income.

By regular mail. You may mail written comments to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number ___, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Generally, you won't have to pay a Part B penalty if you qualify for a Special Enrollment Period. Learn more about Special Enrollment Periods. You'll pay an extra 10% for each year you could have signed up for Part B, but didn't. You may also pay a higher premium depending on your income.

Medicare Part B Penalty The penalty for Part B is a 10% increase on the Part B premium for each full 12-month period not enrolled but eligible. This is a lifelong penalty.

You can voluntarily terminate your Medicare Part B (medical insurance). It is a serious decision. You must submit Form CMS-1763 (PDF, Download Adobe Reader) to the Social Security Administration (SSA). Visit or call the SSA (1-800-772-1213) to get this form.

This penalty is equal to 10% for every year (12 full months) that you waited to enroll, and is added your monthly premium. This penalty gets applied against the standard Part B premium. Keep in mind that the national Part B premium may change each year.

The Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, CMS -1763, is a standard US Department of Health and Human Services form, used by the Medicare enrollee who wishes to terminate their Premium Hospital (premium Part A) and Supplementary Medical Insurance (Part B).

If Medicare's contractor decides that all or part of your late enrollment penalty is wrong, the Medicare contractor will send you and your drug plan a letter explaining its decision. Your Medicare drug plan will remove or reduce your late enrollment penalty.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232