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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 EXECUT....

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You should send your CMS-1763 form to your local Social Security office. Check the official Social Security website to find the correct mailing address depending on your location. Properly addressing your envelope helps avoid delays in processing your request. Additionally, you can consult uslegalforms for more assistance in navigating this process.

Filling out the CMS-1763 PDF form is straightforward. First, download the form from the Medicare website or uslegalforms, which might offer fillable options. Carefully follow the instructions provided with the form, ensuring you complete all required sections. Once finished, print the form and mail it to the designated address.

To cancel your Social Security Medicare Part B, you will need to submit the CMS-1763 form. Make sure you complete the form accurately and mail it to your local Social Security office for processing. You may choose to check uslegalforms for additional tips on completing the process smoothly. This step allows you to stop your Medicare coverage on your terms.

The CMS-1763 form is a request to voluntarily terminate your Medicare Part B coverage. This form is necessary for those who no longer wish to keep their Medicare Part B benefits. You can obtain the CMS-1763 from the Medicare website or via uslegalforms, which provides additional guidance on filling it out. Understanding this form is crucial to manage your Medicare coverage effectively.

You should mail your Medicare forms, including the CMS-1763, to your local Social Security office. Each office has a designated mailing address, which you can find on the Medicare website or uslegalforms platform. For a smooth submission process, use certified mail or another trackable service. This approach gives you peace of mind that your forms are received.

To terminate your Medicare Part B, you will need to fill out the CMS-1763 form. You can download this form from the official Medicare website or uslegalforms platform, which offers a user-friendly interface. Once you complete the form, submit it to your local Social Security office. This process helps ensure that you stop your Medicare Part B coverage efficiently.

To send your CMS-1763 form in the USA, you typically mail it to your local Social Security office. It is important to check the official Social Security website for the precise address based on your location. Additionally, ensure you keep a copy of the form for your records. Using the correct mailing address ensures your request gets processed without delays.

In most cases, if you don't sign up for Medicare Part B when you're first eligible, you'll have to pay a late enrollment penalty. You'll have to pay this penalty for as long as you have Part B and could have a gap in your health coverage.

You can voluntarily terminate your Medicare Part B (medical insurance). However, since this is a serious decision, you may need to have a personal interview. A Social Security representative will help you complete Form CMS 1763. ... You can also contact your nearest Social Security office.

Enrollee Name. Medicare Claim Number. Name of the Person Executing the Request (if appropriate) Determination of the coverage requiring termination. If you want to opt-out of both coverages, check them. End Date of the Insurance. Reasons for the termination request. Signature. Address.

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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
CMS-1763
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