Crosswalk

Revisions to Form CMS-1763 (OMB 0938-0025) REQUEST FOR TERMINATION OF PREMIUM HOSPITAL
AND/OR SUPPLEMENTARY MEDICAL INSURANCE
CMS-1763A Request to Cancel Medicare Part B (Medical Insurance)

This form was updated to add “Part B Immunosuppressive Drug Coverage (Part B-ID)” to the title of the form.
Premium Hospital and Supplementary Medical Insurance were updated to “Medicare Premium Part A and Part
B”.
This form was updated to include a Medicare Part B cancellation version of the form, the CMS-1763A. This form is
used by beneficiaries that are not yet enrolled in Medicare Part B and gives them an option to cancel enrollment
before the automatic enrollment is processed, whereas CMS-1763 allows individuals to terminate enrollment
once it is already active.
This form was also redesigned to be more in line with other recently updated A/B forms and to support the Office
of Communications’ (OC) plain language suggestions.

Changes
Updated Form

Original Form

Reason for Change

Page 1:

Page 1:

Form title: Request for
Termination of
Medicare Premium Part
A, Part B, or
Part B
Immunosuppressive
Drug Coverage (Part BID)

Form title: REQUEST
FOR TERMINATION OF
PREMIUM PART A,
PART B, OR
PART B
IMMUNOSUPPRESSIVE
DRUG COVERAGE

Per Office of Communications’
(OC) plain language suggestion,
the language is being updated to
be more easily digested by
individuals.

Removed Cover page
since that information is
repetitive and evident
when completing the
form.

There isn’t a privacy
statement on the front
page, or anywhere on
the form.

The paragraph
explaining the purpose
of the form has been
updated based on OC’s

Removed option for
individual to choose
their Part A and Part B
end date, since that is

This form format is being
updated to mirror the format of
other recently updated Medicare
Part A and B enrollment forms.
The new format is organized so
that the information is not
overwhelming to the individuals
filing the forms.
We also added the email address
line to have our forms more in
line with current communication
standards.

Burden
Effect
N/A

plain language
suggestion.

determined by the filing
date.

Added an email field for
the enrollee

We added more detail to the
attestation because the previous
version did not specifically attest
to each statement.

Added a field for
individuals to provide
their email address

We added the “note” section to
clarify for individuals when
exactly they can expect their
coverage to end.

Included notes for
clarification on
termination timeline
Removed option for 2nd
witness to be more
aligned with other A/B
forms.

We removed the option for a 2nd
witness to have uniformity across
all A/B forms, all the other forms
only require the signature of one
witness.

Page 2:

Page 2:

Added information on
how to submit the form

N/A

Added Privacy Act
Statement and
Paperwork Reduction
Act

Going forward, all renewed
Medicare A/B forms will include a
privacy statement.

N/A

1763A:

1763A:

Utilized to cancel
Medicare before
automatic enrolment is
processed.

N/A

We propose adding a
supplemental form to the CMS1763, called CMS-1763A, to
provide beneficiaries not yet
enrolled with a cancellation
option before automatic
enrollment occurs. This addition
would reduce payment issues
and processing times, as
technicians would no longer need
to terminate unwanted benefits
after enrollment begins, and
beneficiaries would avoid charges
for benefits they do not want.
Furthermore, it would improve
our data by distinguishing
between individuals who
terminated their Medicare
coverage after it began, and
those who canceled their
coverage before it started,
potentially influencing future
policy decisions. This addition
would also align our forms more
closely with verbiage used by the
Social Security Administration
regarding termination vs
cancellation. Overall, this change
would lower costs and allow
technicians more time to focus
on other tasks.