Form CMS-1763 Request for Termination of Premium Hospital and/or Suppl

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMB No. 0938-0025

REQUEST FOR TERMINATION OF PREMIUM HOSPITAL
AND/OR SUPPLEMENTARY MEDICAL INSURANCE

DO NOT WRITE IN THIS SPACE

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.
NAME OF ENROLLEE (Please Print)

NAME OF PERSON, IF OTHER THAN ENROLLEE, WHO IS
EXECUTING THIS REQUEST.

MEDICARE CLAIM NUMBER

THIS IS A REQUEST FOR
TERMINATION OF
HOSPITAL INSURANCE
MEDICAL INSURANCE

DATE SUPPLEMENTARY
MEDICAL INSURANCE
WILL END

DATE HOSITAL
INSURANCE
WILL END

I request termination of my enrollment under the above section(s) 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 SUPPLEMENTARY MEDICAL INSURANCE COVERAGE
WILL ALSO END MY HOSPITAL INSURANCE COVERAGE. 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 0938-0025. The time required to complete this information collection is
estimated to average 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer,
7500 Security Boulevard, Baltimore, Maryland 21244-1850.
If this request has been signed by mark (X), two witnesses who
know the applicant must sign below, giving their full addresses.

SIGNATURE (Write in Ink)

1. NAME OF WITNESS

SIGN
HERE

ADDRESS

MAILING ADDRESS

(Number and Street, City, State and Zip Code)

(Number and Street)

2. NAME OF WITNESS

CITY, STATE, ZIP CODE

ADDRESS

DATE (Month, Day and Year)

(Number and Street, City, State and Zip Code)

Form CMS-1763 (08/06)

TELEPHONE NUMBER