Fill out CMS-1763 Online in 2025

What is Form CMS-1763?

Form CMS-1763 is used to request the termination of Premium Hospital Insurance and/or Supplementary Medical Insurance. This form is important for individuals who no longer need these insurance coverages, as it helps stop unnecessary payments and ensures that your Medicare coverage aligns with your current needs.

What is Form CMS-1763 used for?

Form CMS-1763, Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, is used by individuals to stop their Medicare coverage. It's used to request termination of Medicare Part A, request termination of Medicare Part B, and avoid premium costs for unwanted coverage.

How to fill out Form CMS-1763?

1. Open the CMS-1763 form in Profi PDF editor

2. Fill out your personal information, including your name, address, and Medicare number

3. Indicate the type of insurance you wish to terminate by checking the appropriate boxes

4. Review all information for accuracy

5. Sign the form electronically

6. Download the completed form for your records

7. Submit the form to your local Medicare office as instructed

Who is required to fill out Form CMS-1763?

Individuals enrolled in Medicare who wish to cancel their insurance coverage fill out form CMS-1763. This includes those needing to terminate their Premium Hospital and/or Supplementary Medical Insurance. After submission, the Centers for Medicare & Medicaid Services processes the form to update the individual's coverage status.

When is Form CMS-1763 not required?

If you are not enrolled in Medicare Part B or if you already have other health coverage that meets Medicare's requirements, you do not need to file form CMS-1763. Additionally, if you are not requesting to terminate your premium hospital or supplementary medical insurance, this form is unnecessary.

When is Form CMS-1763 due?

The deadline for form CMS-1763 is not strictly defined, as you can submit it anytime. However, it is important to file it in a timely manner to ensure your Medicare coverage ends at the desired time. The request will be effective at the end of the month in which you file it.

How to get a blank Form CMS-1763?

To get a blank CMS-1763 form, which is issued by the Centers for Medicare & Medicaid Services (CMS), visit our website. We have a pre-loaded version ready for you to fill out. Remember, while our platform helps you download the completed form, it does not support filing.

How to sign Form CMS-1763 online?

To sign form CMS-1763, start by opening our platform and clicking on "Fill Form" to load the blank version of the document. Complete the necessary fields and, when ready, create a simple electronic signature using the tool provided. Once the signature is in place, click "Done" to download the completed form.

Where to file Form CMS-1763?

Form CMS-1763 must be submitted to the Social Security Administration (SSA). Submitting options include mail, fax or in person at your local SSA office. Make sure to keep a copy for your records.