Form CMS-1763, Request for Termination of Medicare Coverage Instructions
This form contains 18 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Contact Information | ||
| Witness 1 Mailing Street Address | Text |
Provide the mailing street number and name for the first witness.
|
| Witness 1 Mailing City State Zip Code | Text |
Provide the mailing city, state, and zip code for the first witness.
|
| Applicant Signature Date | Date |
Enter the date the applicant signed the form.
|
| Applicant Telephone Number | Text |
Enter the applicant's telephone number.
|
| Coverage Termination | ||
| Hospital Insurance | Radiobutton |
Check this box if you are requesting the termination of your Hospital Insurance (Medicare Part A).
|
| Medical Insurance | Radiobutton |
Check this box if you are requesting the termination of your Medical Insurance (Medicare Part B).
|
| Part B Immunosuppressive Drug Coverage | Radiobutton |
Check this box if you are requesting the termination of your Part B Immunosuppressive Drug Coverage.
|
| Enrollee Information | ||
| Enrollee Name | Text |
Please provide the full name of the enrollee as it appears on their Medicare records.
|
| Medicare Number | Text |
Please enter the enrollee's Medicare Beneficiary Identifier (MBI) or Medicare claim number.
|
| First Witness Information | ||
| First Witness Name | Text |
Please provide the full name of the first witness.
|
| First Witness Address | Text |
Please provide the full address of the first witness, including number, street, city, state, and zip code.
|
| Name of Person Executing Request | ||
| Name of Person Executing Request | Text |
Provide the full name of the person executing this request, if this person is different from the enrollee. Fill only if 'Enrollee Name' is different from the value in 'NAME OF ENROLLEE (Please Print)'.
Depends on:
Enrollee Name
|
| Reason for Termination | ||
| Reason for Termination | Text |
Please provide a detailed explanation for your request to terminate your enrollment.
|
| Second Witness Information | ||
| Second Witness Name | Text |
Please provide the full name of the second witness.
|
| Second Witness Address | Text |
Please provide the complete address, including number, street, city, state, and zip code, for the second witness.
|
| Termination Dates | ||
| Part A End Date | Date |
Enter the date on which Part A coverage will end. Fill only if 'Hospital Insurance' is 'Yes'.
Depends on:
Hospital Insurance
|
| Part B End Date | Date |
Enter the date on which Part B coverage will end. Fill only if 'Medical Insurance' is 'Yes'.
Depends on:
Medical Insurance
|
| PBID End Date | Date |
Enter the date on which PBID (Part B Immunosuppressive Drug Coverage) will end. Fill only if 'Part B Immunosuppressive Drug Coverage' is 'Yes'.
Depends on:
Part B Immunosuppressive Drug Coverage
|