Track Change: Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage

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

Form Approved
OMB No. 0938-0025 (Expires: TBD)

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)
MEDICARE NUMBER

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

THIS IS A REQUEST FOR
TERMINATION OF

DATE SUPPLEMENTARY
DATE HOSPITAL INSURANCE
MEDICAL INSURANCE WILL END WILL END

HOSPITAL INSURANCE
MEDICAL INSURANCE
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 SUPPLEMENTARY MEDICAL
INSURANCE COVERAGE WILL ALSO END MY HOSPITAL INSURANCE COVERAGE.
SIGNATURE (Write in Ink)
If this request has been signed by mark (X), two witnesses who know the
applicant must sign below, giving their full addresses.
SIGN
1. NAME OF WITNESS
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 0938-0025. The time required to complete this
information collection is estimated to average 10 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.
Form CMS-1763 (08/06)