Form CMS-1763, Request for Termination of Medicare Coverage Instructions
This form contains 18 fields organized into 6 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Coverage Termination | ||
| Hospital Insurance | RadioButton |
Check this box to end your Medicare Hospital Insurance (Part A) coverage.
|
| Part A Termination Date | Text |
Enter the date on which your Medicare Part A (hospital insurance) coverage will end.
|
| Part B Termination Date | Text |
Enter the date on which your Medicare Part B (medical insurance) coverage will end.
|
| Part B Immunosuppressive Drug Coverage Termination Date | Text |
Enter the date on which your Medicare Part B immunosuppressive drug coverage will end.
|
| Medical Insurance | RadioButton |
Check this box to end your Medicare Medical Insurance (Part B) coverage.
|
| Part B Immunosuppressive Drug Coverage | RadioButton |
Check this box to end your Medicare Part B immunosuppressive drug coverage.
|
| Enrollee Information | ||
| Name of Enrollee | Text |
Enter the full name of the Medicare enrollee as printed on official records.
|
| Medicare Number | Text |
Provide the enrollee’s Medicare identification number exactly as it appears on the Medicare card.
|
| Mailing Address | Text |
Enter the number and street of your mailing address.
|
| City, State, ZIP Code | Text |
Enter the city, state, and ZIP code of your mailing address.
|
| Telephone Number | Text |
Enter the daytime telephone number where you can be reached regarding this request.
|
| Reason for Termination | ||
| Reason for Termination | Text |
Enter the reason(s) you are requesting termination of your Medicare coverage (Part A, Part B, or Part B immunosuppressive drug coverage).
|
| Representative Information | ||
| Name of Person Executing Request | Text |
Enter the full name of the individual signing this form if other than the enrollee.
|
| Request Information | ||
| Date | Text |
Enter the date you signed this form (month, day, and year).
|
| Witness Information | ||
| First Witness Name | Text |
Enter the full legal name (first, middle initial, last) of the first witness who knows the applicant.
|
| First Witness Address | Text |
Enter the street number, street name, city, state, and ZIP code of the first witness.
|
| Second Witness Name | Text |
Provide the full legal name of the second witness.
|
| Second Witness Address | Text |
Provide the full mailing address of the second witness, including number and street, city, state, and ZIP code.
|