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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 08/06 TELEPHONE NUMBER. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No* 0938-0025 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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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.

You must submit Form CMS-1763 (not available online) 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.

Welcome to Medicare! NOTE: If you don't get Part B when you are first eligible, you may have to pay a lifetime late enrollment penalty. However, you may not pay a penalty if you delay Part B because you have coverage based on your (or your spouse's) current employment.

You can voluntarily terminate your Medicare Part B (medical insurance). ... To find out more about how to terminate Medicare Part B or to schedule a personal interview, contact us at 1-800-772-1213 (TTY: 1-800-325-0778) between Monday through Friday from 8:00 am 7:00 pm.

Most people do not pay a premium for Medicare Part A hospital insurance, so there is no mechanism to cancel it in this case. But if you do pay a premium for Part A and wish to cancel it, you may do so by visiting your local Social Security office or by calling 1-800-772-1213 (TTY 1-800-325-0778).

You Need Part B if Medicare Is Primary Once you retire and have no access to other health coverage, Medicare becomes your primary insurance. Part A pays for your room and board in the hospital. Part B covers most of the rest. Enrolling in Part B when Medicare is primary will help you avoid unexpected medical bills.

Medicare Part B (medical insurance) helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.

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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