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  • Disenroll Medco Form

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Disenrollment Instructions: If you wish to disenroll from Group MedicareBlue Rx, please carefully read and complete all sections on this form. Notify your employer or union contact of your intent.

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Voluntary Termination of Medicare Part B 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. You'll need to have a personal interview with Social Security before you can terminate your Medicare Part B coverage.

Feel free to drop your Part B coverage if you wish. The Part B premiums might not be worth any additional coverage you receive. But if you have secondary-payer insurance at work, it's usually better to keep Part B, or you could get stuck paying Medicare's share of your health care expenses.

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.

Call us at 1-800 MEDICARE (1-800-633-4227). TTY: 1-877-486-2048. Mail or fax a signed written notice to the plan telling them you want to disenroll. Submit a request to the plan online, if they offer this option.

Here's how it works. Draw your signature, type it, upload its image, or use your mobile device as a signature pad. Send form cms 1763 via email, link, or fax. You can also download it, export it or print it out.

In person: Your local Social Security office. For an office near you check .ssa.gov.

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© Copyright 1997-2025
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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