Form CMS-1763
Request for Termination of Premium Hospital and/or Supplementary Medical Insurance
Used by Medicare beneficiaries to voluntarily disenroll from Medicare Part A and/or Part B coverage.
Fill out Form CMS-1763 free — no software, no printing, no account required.
About Form CMS-1763 — Request for Termination of Premium Hospital and/or Supplementary Medical Insurance
Form CMS-1763 is completed by Medicare beneficiaries who wish to voluntarily terminate their Medicare Part A (Hospital Insurance) and/or Part B (Medical Insurance) enrollment. This is uncommon and typically taken when a beneficiary is covered by another qualifying health plan. Because terminating Medicare can affect Social Security retirement benefits, CMS requires the form to be completed in person at a Social Security Administration office rather than by mail. Beneficiaries should carefully consider the implications before disenrolling, as re-enrollment may involve waiting periods and premium surcharges.
How to Fill Out Form CMS-1763 Online
- 1
Open Form CMS-1763 in the editor
Click "Fill Out Form CMS-1763 Online" above. The form loads instantly in your browser — no app, no software, no printing.
- 2
Complete every field
Type directly into each field of the official Form CMS-1763 form. Required fields are clearly labeled and the form auto-tabs for speed.
- 3
Sign electronically
Add your legally compliant e-signature directly on the form — no need to print, sign by hand, and re-scan.
- 4
Download your completed PDF
Export a clean, print-ready Form CMS-1763 PDF in seconds. File it, mail it, fax it, or save it to your device.
Form CMS-1763 is an official form published by CMS / SSA. Official source
Related Healthcare Forms
Application for Enrollment in Medicare Part B
Apply for Medicare Part B (Medical Insurance) coverage for doctor visits, outpatient care, and medical equipment.
Medicare Part D Enrollment Request
Enroll in or change a Medicare prescription drug plan (Part D) outside open enrollment periods.
HIPAA Authorization for Release of Medical Information
Authorizes a healthcare provider to release your protected health information to a specified individual or organization.
Medicare Income-Related Monthly Adjustment Amount
Request to lower Medicare Part B and Part D premiums due to a life-changing event that reduced your income.
Advance Healthcare Directive / Living Will
Documents your healthcare wishes and designates a healthcare proxy to make decisions if you become incapacitated.
Application for Medicaid Benefits
State-administered application to determine eligibility for Medicaid health coverage for low-income individuals and families.