Fill Out Form CMS-1763 in 2026
Document your decision to end premium-paid hospital and medical insurance coverage, sign where allowed, and download your finished copy before your interview.
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How to fill out a CMS-1763 Form
Follow the steps below and you'll finish with no guesswork.
Open the form
Access the pre-loaded form and locate the Name of Enrollee and Medicare Number fields.
Fill in your details
Complete every required field, including insurance type and termination date.
Download as PDF
Save your completed form as a PDF, including your signature, ready to keep.
What is a CMS-1763 Form?
Form CMS-1763 is the document you use to formally cancel premium Medicare coverage. It covers Part A (hospital insurance), Part B (medical insurance), or Part B-ID. You can only end Part A if you pay a premium for it, but you can cancel Part B at any time. Ending Part B also ends premium Part A. Filing this form creates a clear, documented request, so you avoid losing coverage by accident.
Key Takeaways
- Form CMS-1763 cancels Medicare Part A or B
- Part A termination requires premium payment
- Ending Part B also ends Part A coverage
What is a CMS-1763 Form used for?
This form records your voluntary choice to end Medicare coverage you pay premiums for. It's used to:
- Stop premium-paid Part A (Hospital Insurance) coverage
- Stop Part B (Supplementary Medical Insurance) coverage
- Confirm you understand that ending Part B also ends Part A if you pay premiums for it
- Document a required personal interview with an SSA representative before the change takes effect
What information is required on a CMS-1763 Form?
Name of Enrollee / Medicare Number
Enter the enrollee's full name and Medicare number exactly as shown on the Medicare card.
Name of Person (if not the enrollee)
Print the name of the person signing this request if that person is not the enrollee.
Type of Insurance to Terminate
Check whether you want to end Supplementary Medical Insurance, Hospital Insurance, or both.
Requested Termination Date(s)
Write the exact date you want each checked coverage to stop.
Reason for Termination
Add a short reason for ending coverage, though this entry stays optional.
Signature
Sign in ink, or make your mark if you cannot write a full signature.
Witness Names and Addresses
List two witnesses with their addresses only when you sign with a mark instead of a signature.
Mailing Address and Telephone Number
Give your current mailing address and phone number so Social Security can reach you.
When is a CMS-1763 Form due?
The CMS-1763 Form has no fixed deadline. You can file it to terminate Part B or Part B-ID whenever you choose, though Part A termination only applies if you pay a premium for it. Coverage doesn't end right away — Part B stops on the last day of the month after you file, so submit once you've decided, since an SSA interview must happen first.
End your coverage request now
Open Form CMS-1763 here, fill in your termination details, and download the completed copy for your records.
When is a CMS-1763 not required?
No termination paperwork applies if you were never enrolled in premium Part A or Part B, since there's no coverage to end. The same holds once other qualifying health coverage takes over your benefits. Even then, an SSA representative completes the form during your interview, so you never fill it out yourself.
What does a CMS-1763 form look like
Frequently asked questions
