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.
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 |
