Form CMS-1763, Request for Termination of Medicare Coverage Completed Form Examples and Samples

Explore an example of a filled Form CMS-1763, designed to request the termination of Medicare Part B coverage due to new employment with health benefits. This detailed guide provides insights into accurate form completion, using a real-life scenario with personal details, coverage information, and termination reasons.
Form CMS-1763, Request for Termination of Medicare Coverage has a basic Form Complexity Index of 40/100 — Instafill’s AI completes it in under a minute.
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Completed CMS-1763 Form for terminating Part B Medicare due to employment reasons

CMS-1763 Example – Terminating Part B Coverage for Employment Reasons

How this form was filled:

This example demonstrates how to fill out the CMS-1763 form to terminate Medicare Part B coverage due to gaining employment with benefits. It includes personal details, coverage information, and the employment start date.

Information used to fill out the document:

  • Name: Jane Smith
  • Social Security Number: 123-45-6789
  • Date of Birth: 04/02/1960
  • Phone Number: 555-0123
  • Address: 456 Elm Street, Metropolis, USA
  • Reason for Termination: Gained employment with group health benefits
  • Employment Start Date: 02/01/2025
  • Medicare Number: 1EG4-TE5-MK72
  • Signature: Jane Smith
  • Date Signed: 01/15/2025

What this filled form sample shows:

  • Accurate completion of personal details including name and SSN
  • Valid reason for termination: gaining employment with health benefits
  • Correct entry of employment start date in 2025
  • Properly formatted signature and date

Form specifications and details:

Use Case: Terminating Medicare Part B due to new employment benefits
Form Purpose: Discontinue Medicare Part B coverage
Target Audience: Individuals transitioning to employment-provided health coverage in 2025
Categories: CAR forms, CMS forms, ERM forms, Medicare forms, L.A. Care forms
Completed CMS-1763 Form for terminating Part B Medicare due to employment reasons