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How to fill out the CMS-1763 online
The CMS-1763 form allows individuals to voluntarily request the termination of their Medicare coverage. This guide provides clear, step-by-step instructions to effectively complete the form online.
Follow the steps to complete the CMS-1763 form with ease.
- Click ‘Get Form’ button to obtain the CMS-1763 form and open it in the editor.
- Begin by filling in the 'Name of enrollee' field, entering the complete name of the individual who is terminating their Medicare coverage.
- If applicable, provide the 'Name of person, if other than enrollee, who is executing this request' to identify the individual completing the form.
- Enter the 'Medicare claim number' that corresponds to the enrollee's Medicare coverage.
- Indicate the type of insurance being terminated by checking the appropriate box for either 'Hospital insurance' or 'Medical insurance.' You may select both if applicable.
- Fill in the 'Date supplementary medical insurance will end' with the intended termination date for the supplementary coverage.
- Provide the 'Date hospital insurance will end' to specify when the hospital insurance is expected to cease.
- In the space provided, describe any reason(s) for your request for termination, although this is not required.
- Read and acknowledge your understanding of the implications of terminating coverage by reviewing the statement that advises that ending supplementary insurance will also end hospital insurance if applicable.
- If the request is signed by mark (X), ensure two witnesses sign the form. Include their names and complete mailing addresses.
- Finally, sign and date the form in the designated area. After completing all sections, you can opt to save changes, download, print, or share the form as needed.
Take the next step and complete your CMS-1763 form online today.
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