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Get CMS-1763 1997

SIGNATURE Write in Ink 1. NAME OF WITNESS SIGN HERE ADDRESS MAILING ADDRESS Number and Street City State and Zip Code CITY STATE ZIP CODE DATE Month Day and Year Form CMS-1763 05/97 TELEPHONE NUMBER. Form Approved OMB No* 0938-0025 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE DO NOT WRITE IN THIS SPACE 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* While you are not required to give your reasons for requesting termination the information given will be used to document your understanding of the effects of your request. NAME OF ENROLLEE Please Print NAME OF PERSON IF OTHER THAN ENROLLEE WHO IS EXECUTING THIS REQUEST. MEDICARE CLAIM NUMBER THIS IS A REQUEST FOR TERMINATION OF HOSPITAL INSURANCE MEDICAL INSURANCE DATE SUPPLEMENTARY WILL END DATE HOSITAL INSURANCE I request termination of my enrollment under the above sections of title XVIII of the Social Security Act as amended for the reason s stated below I UNDERSTAND THAT IF I AM REQUIRED TO PAY FOR MY HOSPITAL INSURANCE THE TERMINATION OF MY SUPPLEMENTARY MEDICAL INSURANCE COVERAGE WILL ALSO END MY HOSPITAL INSURANCE COVERAGE* According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0025. The time required to complete this information collection is estimated to average 25 minutes per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection* If you have any comments concerning the accuracy of the estimate s or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850. If this request has been signed by mark X two witnesses who know the applicant must sign below giving their full addresses. Form Approved OMB No* 0938-0025 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE DO NOT WRITE IN THIS SPACE 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* While you are not required to give your reasons for requesting termination the information given will be used to document your understanding of the effects of your request. .

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