CMS 1763 Form – Free PDF | Fill Online in Minutes

CMS Form CMS 1763

2025 Printable Template

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Form last updated: 03/2024. Please verify this is the current version before use.

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What is a CMS 1763 used for?

Form CMS-1763 is used to request the termination of Medicare Part A (Premium Hospital Insurance) and/or Part B (Supplementary Medical Insurance). This form is necessary for individuals who wish to discontinue their Medicare coverage to avoid paying unnecessary premiums.

Who needs to fill out a CMS 1763 form

Individuals enrolled in Medicare Part A and/or Part B who wish to terminate their coverage.

How to fill out a CMS 1763 online?

Follow these steps to complete your CMS 1763 form online.

Step 1

Obtain Form CMS-1763 from the Social Security Administration (SSA) office.

Step 2

Fill in your personal details accurately.

Step 3

Indicate the insurance coverage you wish to terminate by checking the relevant boxes.

Step 4

Review all entered information for correctness.

Step 5

Sign the form.

Step 6

Submit the form to your local Social Security Administration office.

Centers for Medicare & Medicaid Services

Frequently Asked Questions

Find quick answers to common questions about our PDF editor.

What is Form CMS-1763?

Form CMS-1763 is a request to terminate Medicare coverage, specifically for Premium Hospital and/or Supplementary Medical Insurance.

When is Form CMS-1763 not necessary?

This form is not required if you are not enrolled in Medicare Part A or Part B.

Where should I send Form CMS-1763?

The completed form should be submitted to your local Social Security Administration office.

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