CMS 1763 Form: Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance

• You can’t simply fill and submit form CMS-1763 online yourself. SSA requires a short phone or in-person interview with a Social Security representative first. After that, you’ll complete, sign, and submit the form as instructed (typically by mail, fax, or drop-off at your local Social Security office).
• Return your Medicare card if you drop Part B. You’ll receive a replacement Medicare card reflecting your remaining coverage (e.g., Part A only).
• When coverage ends: For voluntary Part B termination, coverage ends the last day of the month after the month you file your termination request. (Example: file on April 5 → Part B ends May 31.)
• 2025 costs (for comparison): Standard Part B premiums are $185/month; the annual Part B deductible is $257. After the deductible, you typically pay 20% coinsurance.
• Re-enrollment later: If you had alternative insurance coverage due to current employment, you may re-enroll during a Special Enrollment Period (SEP) without a penalty. Otherwise, you’ll use the General Enrollment Period (Jan 1–Mar 31), with coverage starting the month after you enroll (and late penalties may apply).

Thinking about a request for termination of your Medicare coverage? The CMS-1763 form—officially, Request for Termination of Premium Hospital and/or Supplementary Medical Insurance—is what the Social Security Administration (SSA) uses to process cancellations of Premium Hospital Insurance (premium Part A) and Supplementary Medical Insurance (Medicare Part B).

This guide explains when to use Form CMS-1763, what to expect from the SSA interview, how effective dates and premiums work, and how to avoid avoidable gaps and penalties.

What CMS-1763 can (and can’t) do

Form CMS-1763 lets you terminate:

• Part B (Supplementary Medical Insurance), and/or
• Premium Hospital Insurance (premium Part A—applies only if you pay for Part A).

CMS-1763 doesn’t, by itself, end premium-free Part A.

If you already have premium-free Part A (most people do) because you’re receiving Social Security retirement or disability benefits, ending Part A requires withdrawing Social Security benefits (and possibly repaying benefits). That’s a major decision—discuss it with SSA before you decide.

Should you cancel Medicare right now?

Run these quick checks before you terminate any coverage:

• Do you have credible alternative coverage today?
  If your health insurance from current employment (yours or your spouse’s) will be primary, cancelling Part B coverage can make sense. Confirm that you’ll be covered for the services you use, and document the employer plan (this helps with future enrollment if you change your mind).
• Will you qualify for a Special Enrollment Period later?
  If you remain on employer group health coverage based on current employment, you generally get an 8-month SEP after that coverage (or employment) ends to enroll in Part B without penalty. If you terminate Part B without qualifying alternative coverage, you may face gaps, penalties, and a wait until the GEP.
• HSA considerations
  Enrollment in any Medicare part (A or B) stops you from making new HSA contributions. Terminating certain parts can change future HSA eligibility—confirm with your employer or tax adviser.

The CMS-1763 process (step-by-step)

Step 1: Contact SSA
Call the Social Security Administration (national line) or your local office and say you want to cancel MedicarePart B and/or Premium Hospital (Part A you pay for) using the social security form CMS-1763. They’ll arrange the required interview (phone or in person) and tell you how to submit the form.

Step 2: Interview with a Social Security representative
During the interview, SSA confirms your identity, discusses your reasons (e.g., switching to alternative coverage), explains consequences, effective dates, and what happens to premiums, billing, and benefits.

Step 3: Complete and sign Form CMS-1763

• Select what you want to cancel: Part B, Premium Hospital Insurance, or both (medicare part options).
• Provide your Medicare number, contact address, and relevant details about alternative insurance coverage (plan name, effective date, based on current employment, etc.).
• Sign and date the document.
• Two witnesses are required only if you sign by mark (e.g., “X”). Otherwise, no witnesses are needed.
  

Step 4: Submit your completed form
SSA will tell you how to submit the completed form: usually by mail, fax, or dropping it at your local Social Security office. Keep a copy of everything you submit. Although Form CMS 1763 is not available for online submission, you can find it in pdfFiller’s library, fill out and easily print it out from your account. We will help complete each field and take you through it step by step.

Step 5: Return your Medicare card
If you’re dropping Part B, return your Medicare card as instructed. SSA will send a new card reflecting your remaining coverage (for example, Part A only). Keep your medicare number handy while you wait.

Step 6: Watch effective dates and billing
Your termination typically takes effect on the last day of the month after the month you submit your request termination. Premiums are due for any month you’re still covered. If premiums are deducted from Social Security, the stop/adjustment will follow SSA’s confirmation; if you get direct bills, continue to pay until SSA confirms your termination to avoid issues.

How to fill out CMS-1763  

1. Name of enrollee.
Write down the enrollee’s full legal name exactly as it appears on their Medicare card. If another individual executes this request on the enrollee’s behalf, write down that person’s name in the appropriate field below. Make sure to use the same spelling and format as recorded with the Social Security Administration to avoid delays.

pdfFiller’s editor allows you to fill out PDF forms by clicking on any field and typing in all required information accurately and legibly.

2. Medicare number.
Indicate your Medicare number exactly as printed on your Medicare card. This is your unique identifier used by the Centers for Medicare & Medicaid Services (CMS). Double-check this entry for accuracy before submission. 

3. Name of the person, if other than enrollee, who is executing the request (if appropriate).
If someone other than the enrollee is completing or signing the CMS-1763 form, enter that person’s full name and their relationship to the enrollee—for example, “spouse,” “authorized representative,” or “power of attorney.” If the enrollee is completing the form personally, leave this field blank.

4. This is a request for termination of hospital insurance/medical insurance.
Here, you must choose the type of Medicare coverage you want to terminate. You can select either:

• Hospital Insurance (Part A) – used if you pay a premium for Premium Hospital Insurance.
• Medical Insurance (Part B) – used to end your supplementary medical insurance coverage.
  You may choose to opt out of both coverages by marking both boxes.

Important: If you have premium-free Part A, you generally cannot terminate it without also withdrawing from Social Security benefits and repaying amounts received. Speak with a Social Security representative before selecting this option.

5. Date hospital insurance/Medical insurance will end.
Indicate the date when your hospital or medical insurance coverage should end. For voluntary Part B termination, coverage usually ends on the last day of the month after the month in which the request is filed. For example, if you file the form on April 5, your Part B ends May 31. You can request a future termination date to match your alternative insurance coverage, but the Social Security Administration will confirm the official effective date in writing.

6. Reasons for the termination request.
In the field provided, describe in detail the reason you wish to cancel Medicare. This explanation is required to demonstrate that you understand the consequences of termination and that you have alternative insurance coverage in place.
Typical reasons include: 

• You or your spouse started a new job that provides health insurance through an employer plan.
• You have qualified for Medicaid services or another government program.
• You are covered under a union or military health plan.
  Provide as much detail as possible. For example: “I started full-time employment on March 1, 2025. My employer offers group health insurance effective April 1, 2025, through UnitedHealthcare. I wish to terminate my Part B coverage because I am now covered under this employer plan.”

This information helps document your understanding of the decision and assists in processing your request termination properly.

7. Signature, address, phone number, and date.
Complete this section carefully. Write your current mailing address, telephone number, and the date of completion. Sign the form to acknowledge that you fully understand the consequences of ending your Medicare benefits.

If someone else is signing on your behalf, they must also identify their relationship to you and provide proof of authorization (for example, power of attorney or representative payee documentation).

Once the form is complete, you can create a legally binding eSignature by drawing, typing, or uploading a signature image, finalizing your claim securely from your device.

8. If the applicant signs by mark (“X”).
If the enrollee is unable to write a full signature and instead signs with an “X,” the form must also be signed by two witnesses. The witnesses must provide their names and mailing addresses clearly.

These witnesses should know the applicant personally and be able to verify that the form was signed voluntarily. Witnesses may include family members, friends, or neighbors.

By completing all the sections above accurately, you ensure that your termination request is processed efficiently by the Social Security office and that your Medicare coverage ends on the correct date. Always keep a copy of the completed form for your own records and return your Medicare card if you are cancelling Part B.

Part-specific reminders

Terminating Part B (Supplementary Medical Insurance)

• Most common scenario when you have qualifying employer coverage.
• You’ll stop paying Part B premiums after the effective date.
• You can usually re-enroll later through a Special Enrollment Period if you kept employer coverage based on current employment.

Terminating Premium Part A (Premium Hospital Insurance)

• Applies only if you pay a premium for Part A (not premium-free).
• Use CMS-1763 with SSA guidance, just like for Part B.

Trying to Terminate Premium-Free Part A

• If you receive Social Security benefits, ending premium-free Part A requires withdrawing Social Security and may require repayment of benefits. This is complex—discuss with a Social Security representative before you proceed.

Costs & timing you should know (2025)

• Part B premium: $185/month (income-adjusted for higher earners).
• Part B annual deductible: $257.
• Part B coinsurance: typically 20% after the deductible.
• Autodeduction: Many people have premiums taken automatically from their Social Security payment (you may not receive paper billing).
• Effective date: Part B ends the last day of the month after the month you file your termination.

(Figures provided to help you compare against alternative insurance coverage; confirm the latest amounts with SSA/CMS if reading later in the year.)

If you change your mind: How re-enrollment works

• Special Enrollment Period (SEP) — If you keep employer group health coverage based on current employment, you can enroll in Part B any time while covered or during the 8-month SEP that starts after employment or coverage ends (whichever comes first). You’ll typically use CMS-40B (Application for Part B) and CMS-L564 (Request for Employment Information). Online submission/upload is commonly available for these forms.
• General Enrollment Period (GEP) — If you don’t qualify for an SEP, you can enroll Jan 1–Mar 31. Coverage starts the first day of the month after you enroll. Late penalties can apply if you didn’t have creditable alternative coverage. 

Quick checklist before you submit your CMS-1763 form

• Confirm alternative coverage (plan name, ID, effective date, based on current employment if applicable).
• Gather your Medicare card, medicare number, and address.
• Call SSA / your local Social Security office to schedule the interview.
• Fill and sign Form CMS-1763 (form cms); include two witnesses only if signing by mark.
• Submit the completed form exactly as instructed (by mail, fax, or in person at the local office).
• Return your Medicare card if dropping Part B.
• Watch for SSA’s written confirmation and verify billing/premiums stop on time.
• Keep copies of the forms, letters, and proof of coverage (employer verification, Medicaid, or other alternative coverage). 

Where to get help

• Social Security Administration — Your first stop for CMS-1763, the interview, and official submission instructions. Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
• Local Social Security office — For in-person assistance, additional questions, and document drop-off.
• Medicare (Centers for Medicare & Medicaid Services) — For Medicare benefits, plan comparisons, and general services information.
• Employer benefits team — For coordination with alternative insurance coverage and data needed for CMS-L564.

Where should Form CMS-1763 be sent?

Form CMS-1763 is completed during or after a brief interview with a Social Security Administration (SSA)representative. Once all fields are filled out, submit your completed form to your local Social Security office—typically by mail, fax, or in person, as instructed by SSA.

While Form CMS-1763 isn’t accepted for online submission, you can access it in pdfFiller’s library to fill, print, and prepare it for delivery. Our guided workflow walks you through each field step by step, so you can confidently finalize and submit your paperwork.

Simplify your paperwork and save time. With pdfFiller, you can easily fill, sign, and manage essential Medicare documents like the Form CMS-1763—all in one secure platform. Start your free trial of pdfFiller today to complete your CMS-1763 form quickly, print it for submission to your local Social Security office, and stay organized every step of the way.

Important disclaimer

This article summarizes common SSA/CMS practices for ending Part B and/or premium Part A. Rules can change and individual situations vary. Always confirm process and effective dates with a Social Security representative at your local Social Security office before you submit your CMS-1763.

Glossary

• Alternative insurance coverage: Any health insurance other than Medicare, such as an employer’s group plan, union plan, or Medicaid services, providing medical or hospital insurance benefits.
• Centers for Medicare & Medicaid Services (CMS): The federal agency that administers Medicare, Medicaid, and other national health programs, and issues official documents like Form CMS-1763.
• Hospital insurance (Medicare Part A): Covers inpatient hospital care and related services. For those who pay premiums, it’s called Premium Hospital Insurance and can be ended via Form CMS-1763.
• Medical insurance (Medicare Part B): Also known as Supplementary Medical Insurance, covering outpatient and preventive care. Requires monthly premiums and can be cancelled using Form CMS-1763.
• Medicare card: The identification document showing your Medicare number and coverage type. When cancelling Part B, you must return your card; a new one will be issued to show your remaining coverage.