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CMS 1763: How to Opt Out of Your Medicare Insurance

Form CMS 1763: Termination of Premium Hospital and/or Supplementary Medical Insurance

Having decided to terminate your Medicare insurance, you should make sure you know how the process works. We provide our review of the CMS 1763 Form to help you.

Who needs a CMS 1763 Form?

The Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, CMS -1763, is a standard US Department of Health and Human Services form, used by the Medicare enrollee who wishes to terminate their Premium Hospital (premium Part A) and Supplementary Medical Insurance (Part B). This action is provisioned by the 1818A Section of the Social Security Act.

As a reminder, Medicare is the federal social insurance program developed for US citizens aged 65 and older, people with disabilities of any age, and those who suffer from end-stage renal disease and amyotrophic lateral sclerosis, who are eligible for Social Security Disability Insurance benefits (SSDI).

What is the CMS 1763 Form for?

The CMS 1763 Request form is the only way to terminate Medicare Plan A and Plan B. Considering the seriousness of this decision, filing the form is not the only step required. Most often, before submitting the completed CMS-1763, the claimant will be invited to an interview with a Social Security representative in person, or on the phone. In this case, the claimant will need to explain the reason for the decision, and a Social Security representative will, in turn, explain the procedure and results of the given insurance termination.  A typical situation in which this request is made is when a person or their spouse has found a job which will cover lifetime insurance.

Is the CMS 1763 Form accompanied by other forms?

Filing the Request for Termination of Premium Hospital and/or Supplementary Medical Insurance does not require any supplementary documentation.

When is the CMS 1763 Form due?

The application for Medicare insurance has certain due dates for retired Americans; the application must be filed three months before the applicant’s 65th birthday. The termination of the hospital or medical insurance is not strictly regulated and can be done when considered necessary by the insured person. The termination should be expected at the end of the month that the request is filed.

How do I fill out the CMS 763 Form?

The CMS-1763 form is a single-page document consisting of several items:
• Enrollee name
• Medicare Claim Number
• Name of the Person Executing the Request (if appropriate)
• Determination of the coverage requiring termination
• End Date of the Insurance
• Reasons for termination request
• Signature
• Address
• Phone Number
• Date
If instead of the signature, the applicant signs the form by marking x, then the form must be signed by two witnesses who know the enrollee. They should provide their names and mailing addresses.

Where do I send the CMS-1763 Form?

The CMS 1763 form must be completed only during or after an interview with a representative of the Social Security Administration. Having filled it out completely, the applicant should submit it to the SSA local office.