Track Change: Request for Termination form

Form Approved
OMB No. 0938-0025
Expires: 04/24

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

REQUEST FOR TERMINATION OF PREMIUM PART A, PART B, OR
PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
WHO CAN USE THIS FORM?

WHAT HAPPENS NEXT?

People with Medicare premium Part A or B who would like
to terminate their hospital or medical insurance coverage.

Send your completed and signed application to your local
Social Security office. If you have questions, call Social
Security at 1-800-772-1213. TTY users should call
1-800-325-0778.

WHEN DO YOU USE THIS APPLICATION?
Use this form:
•

If you have premium Part A or Part B, but wish to no
longer be enrolled.

•

If you have Part B, but recently re-joined the workforce
with access to employer-sponsored health insurance
and wish to voluntarily terminate this coverage.

•

If you have Part B, but are now covered under a
spouse’s employer-sponsored health insurance and
wish to voluntarily terminate this coverage.

WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS APPLICATION?
•

Your Medicare number

•

Your current address and phone number

•

A witness and their current address and phone
number, if you signed the form with “X”

•

Date you are requesting to end your premium Part A
or Part B

WHAT ARE THE CONSEQUENCES OF
DISENROLLMENT?
•

•

If you disenroll from Part B, it may result in gaps in
your coverage, and you may incur a late enrollment
penalty of 10% for each full 12-month period you
don’t have Part B but were eligible to sign up and you
don’t have other appropriate coverage in place.
You must have Part B while enrolled in premium
Part A. If you disenroll from Part B, your premium
Part A will also terminate.

HOW DO YOU GET HELP WITH THIS
APPLICATION?
•

Phone: Call Social Security at 1-800-772-1213. TTY users
should call 1-800-325-0778.

•

En español: Llame a SSA gratis al 1-800-772-1213 y
oprima el 2 si desea el servicio en español y espere a
que le atienda un agente.

•

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

REMINDERS
If you’ve already received your Medicare card, you’ll need
to return it to the SSA office or mail it back.

WHAT IF YOU WANT TO RE-ENROLL IN
MEDICARE?
If you do not qualify for a special enrollment period (SEP),
you will need to wait until the general enrollment period
(GEP), which is every year from January—March. Coverage
will be effective the month after the month of the
enrollment request.
If you would like to re-enroll in premium Part A or Part B
you will need to complete the form CMS 18-F-5 or
CMS 40-B. If you qualify for an SEP, youll also need to
attach the following:
•

If you qualify for an SEP based on employer group
health plan coverage, you’ll need to complete the
CMS L564.

•

If you qualify for an SEP based on another
circumstance you’ll need to complete form CMS 10797.

•

The forms will need to be provided to SSA per the
instructions on each individual form.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file
a complaint if you feel you’ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibility-nondiscriminationnotice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

Form CMS-1763 (01/2022)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

REQUEST FOR TERMINATION OF Medicare PREMIUM PART
A, PART B, OR PART B IMMUNOSUPPRESSIVE DRUG
COVERAGE (Part B-ID)

DO NOT WRITE IN THIS SPACE

Use this form to request to end your of Medicare coverage.. You can terminate Part A only if
you pay a premium for it. You can terminate Part B at any time.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.
MEDICARE NUMBERMedicare Number
NAME OF ENROLLEE (Please Print)Name of Enrollee

Mailing Address
City, State, Zip Code

Phone Number
Email Address

I authorize Social Security and Medicare to send me emails about my benefits and coverage.

NAME OF PERSON, IF OTHER THAN ENROLLEE, WHO IS EXECUTING THIS REQUEST. Enrollee (First Name, Middle Name, Last Name

THIS IS A REQUEST FOR TERMINATION OF This is a
request to end my
HOSPITAL INSURANCE Part A Hospital
Insurance
MEDICAL INSURANCE Part B Medical Insurance
PART B IMMUNOSUPPRESSIVE DRUG COVERAGE

DATE PBID WILL END

Enter the month
and year you
want coverage to
end:
MM/YYYY

NOTE: Your Part A/Part B coverage will end the last day of the month
AFTER the month you submit your request. For example, if you submit
your request April 5, your coverage will end May 31.

Note: Your Part
B-ID coverage
will end the last
day of the month
you request. For
example, if you
ask for coverage
to end in April,
your last day of
coverage will be
April 30.

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 want to end my Medicare coverage for these reasons (optional):

Form CMS-1763 (01/2022)

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I UNDERSTAND THAT IF I AM REQUIRED TO PAY FOR MY HOSPITAL INSURANCE, THE TERMINATION OF MY PART B COVERAGE WILL ALSO
END MY PART A COVERAGE.
SIGNATURE (Write in Ink)
If this request has been signed by mark (X), atwo witnesses who knows the
applicant must sign below., giving their full addresses.
SIGN
1. NAME OF WITNESS
HERE
ADDRESS (Number and Street, City, State and Zip Code)

MAILING ADDRESS (Number and Street)

2. NAME OF WITNESS

CITY, STATE, ZIP CODE

ADDRESS (Number and Street, City, State and Zip Code)

DATE (Month, Day and Year)

TELEPHONE NUMBER

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 10 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.

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.
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 10 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.

Form CMS-1763 (01/2022)