Get FORM CMS 1763, REQUEST FOR TERMINATION OF PREMIUM PART A, PART B, OR PART B IMMUNOSUPPRESSIVE DRUG

If you prefer an in-person interview, use the Social Security Office Locator to find your nearest location. During your interview, fill out Form CMS 1763 as directed by the representative.

Send your completed and signed application to your local Social Security office. If you have questions, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

During your interview, fill out Form CMS 1763 as directed by the representative. If you've already received your Medicare card, you'll need to return it during your in-person interview or mail it back after your phone interview. What happens next depends on why you're canceling your Part B coverage.

DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES. Form CMS-1763 (01/2022) REQUEST FOR TERMINATION OF PREMIUM PART A, PART B, OR PART B IMMUNOSUPPRESSIVE DRUG COVERAGE.

Form CMS-1763, or Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, is the only way to terminate hospital insurance (Medicare Plan A) and supplementary medical insurance (Plan B). Considering the seriousness of this decision, filling out the form is not the only step required.

Although Form CMS 1763 is not available for online submission, you can find it in docHubs library, fill out and easily print it out from your account.

To find out more about how to terminate Medicare Part B or to schedule a personal interview, contact us at 1-800-772-1213 (TTY: 1-800-325-0778) or visit your nearest Social Security office.

How do I terminate Medicare Part B? Voluntary Termination of Medicare Part B You must submit Form CMS-1763 (PDF, Download docHub Reader) to the Social Security Administration (SSA). Visit or call the SSA (1-800-772-1213) to get this form.