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DEPARTMENT OF HEALTH AND HUMAN SERVICES |
Form Approved |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
OMB No. |
|
Expires: 04/24 |
REQUEST FOR TERMINATION OF PREMIUM PART A, PART B, OR
PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
WHO CAN USE THIS FORM?
People with Medicare premium Part A or B who would like to terminate their hospital or medical insurance coverage.
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
•If you have Part B, but are now covered under a spouse’s
WHAT HAPPENS NEXT?
Send your completed and signed application to your local Social Security office. If you have questions, call Social Security at
HOW DO YOU GET HELP WITH THIS
APPLICATION?
•Phone: Call Social Security at
•En español: Llame a SSA gratis al
•In person: Your local Social Security office. For an office near you check www.ssa.gov.
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
•You must have Part B while enrolled in premium Part A. If you disenroll from Part B, your premium Part A will also terminate.
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
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
If you would like to
CMS
•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
Form
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
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.
DO NOT WRITE IN THIS SPACE
NAME OF ENROLLEE (Please Print)
MEDICARE NUMBER
NAME OF PERSON, IF OTHER THAN ENROLLEE, WHO IS EXECUTING THIS REQUEST.
THIS IS A REQUEST FOR TERMINATION OF |
DATE PART A |
DATE PART B |
DATE PBID |
HOSPITAL INSURANCE |
WILL END |
WILL END |
WILL END |
MEDICAL INSURANCE |
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PART B IMMUNOSUPPRESSIVE DRUG COVERAGE |
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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 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.
If this request has been signed by mark (X), two witnesses who know the applicant must sign below, giving their full addresses.
1. NAME OF WITNESS
SIGNATURE (Write in Ink)
SIGN
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
Form
Document Information
| Fact Name | Details |
|---|---|
| Form Title | CMS-1763 Exp Form |
| Purpose | This form is used to request the termination of Medicare Part B coverage. |
| Eligibility | Individuals eligible for Medicare can use this form to cancel their Part B enrollment. |
| Submission Method | The form can be submitted by mail or fax to the appropriate Medicare Administrative Contractor. |
| Processing Time | Typically, processing takes about 30 days from the date of submission. |
| State-Specific Forms | Some states may have additional forms or requirements; check local Medicare guidelines. |
| Governing Law | The form is governed by federal Medicare regulations, specifically 42 U.S.C. § 1395. |
| Signature Requirement | A signature is required on the form to validate the request for termination. |
| Effective Date | The termination of coverage becomes effective on the last day of the month in which the form is processed. |
| Contact Information | For questions, individuals can contact Medicare at 1-800-MEDICARE. |
CMS-1763 Exp - Usage Guidelines
Completing the CMS-1763 Exp form is an important step in your process. After filling out the form, you will be able to submit it for review. This will help ensure that your request is processed efficiently.
- Begin by downloading the CMS-1763 Exp form from the official website or obtaining a physical copy.
- Carefully read through the instructions provided with the form to understand the requirements.
- In the first section, fill out your personal information, including your name, address, and contact details.
- Provide your Medicare number if applicable, ensuring it is accurate to avoid any delays.
- In the next section, indicate the reason for your request by checking the appropriate box.
- Complete any additional information requested in this section, providing as much detail as necessary.
- Review the form for any errors or missing information before signing and dating it.
- Make a copy of the completed form for your records.
- Submit the form by mailing it to the address specified in the instructions or by following any alternative submission methods outlined.
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Dos and Don'ts
When filling out the CMS-1763 Exp form, it’s essential to follow specific guidelines to ensure accuracy and compliance. Here’s a list of dos and don’ts to help you through the process.
- Do read the instructions carefully before starting.
- Do provide accurate and complete information.
- Do use clear and legible handwriting if filling out by hand.
- Do double-check your entries for errors before submission.
- Do keep a copy of the completed form for your records.
- Don't leave any required fields blank.
- Don't use abbreviations that may cause confusion.
- Don't submit the form without signing and dating it.
- Don't ignore the deadline for submission.
- Don't forget to include any necessary supporting documents.
Common mistakes
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Incorrect Personal Information: Many individuals fail to provide accurate personal details, such as their name, address, or Social Security number. This can lead to delays or rejection of the form.
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Missing Signature: Some people forget to sign the form. Without a signature, the form is considered incomplete and cannot be processed.
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Not Using the Correct Version: Submitting an outdated version of the CMS-1763 Exp form can create confusion. Always check for the most current version before filling it out.
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Inaccurate Dates: Failing to provide the correct dates for events, such as the start or end of coverage, can lead to complications. Accurate dates are essential for proper processing.
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Overlooking Required Documentation: Some individuals neglect to include necessary supporting documents. These documents are often crucial for verifying eligibility or other claims.
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Using Abbreviations: People sometimes use abbreviations or shorthand that may not be understood by the processing staff. Clear and complete information is vital.
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Providing Inconsistent Information: Inconsistencies between the CMS-1763 Exp form and other submitted documents can raise red flags. Ensure all information matches across forms.
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Neglecting to Review the Form: Some individuals rush through the process and fail to review their answers. A thorough review can catch errors before submission.
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Not Keeping a Copy: Failing to make a copy of the completed form can be a mistake. Keeping a record is important for future reference or follow-up.