CMS-1763A Request to Cancel Medicare Part B (Medical Insurance)

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services

Form Approved | OMB No. 0938-0025
Expires: XX/XXXX

Request to Cancel Medicare Part B (Medical Insurance)
If you don’t want Medicare Part B (Medical Insurance),
complete this form and return it before:
I don’t want Part B

TRICARE enrollees (Military Health Benefits):
Read the Important Notice on the back if you
have other coverage BEFORE you decline Part B

Wage earner’s name (if different from yours)

Social Security Claim Number

Your name

Signature (Do not print)

Mailing address (Number and street, PO Box, or route)

Only signature by mark (X) must be witnessed:
Signature of witness
Date signed

City

Address of witness

CMS-1763A (XX/XX)

State

ZIP code

Date signed

Medicare Part B (Medical Insurance) is automatically included in your Medicare coverage unless you choose to
decline it. If you wish to decline Part B coverage, you must complete and return this form by the date indicated
above. If you take no action, you will be enrolled in Medicare Part B.
Medicare Part B will help you pay your doctor bills and bills for many other medical items and services not
covered under Medicare Part A (Hospital Insurance). Unless you already have broad protection against medical
costs, you will probably benefit by keeping this Medicare protection.
Important Notice about Medicare Part B and Other Health Coverage: If you have other health insurance
coverage, such as TRICARE or certain employer or government plans, you may be required to enroll in
Medicare Part B to keep those benefits. Failing to enroll in Medicare Part B when required could lead to the
loss of your health coverage, higher premiums if you decide to enroll in Part B later, or gaps in your overall
health coverage.
Paperwork Reduction Act: 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-XXXX. The time required to complete this
information collection is estimated to average X 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 comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn.: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. DO NOT MAIL YOUR COMPLETED FORM TO THIS ADDRESS. If you do, we won’t be able to process your form, and your request to release
your personal health information will be significantly delayed.