DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-1763 (01/2022)
Form Approved
OMB No. 0938-0025
Expires: 04/24
REQUEST FOR TERMINATION OF PREMIUM PART A, PART B, OR
PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
WHO CAN USE THIS FORM?
People with Medicare premium Part A or B who would like
to terminate their hospital or medical insurance coverage.
WHEN DO YOU USE THIS APPLICATION?
Use this form:
• If you have premium Part A or Part B, but wish to no
longer be enrolled.
• If you have Part B, but recently re-joined the workforce
with access to employer-sponsored health insurance
and wish to voluntarily terminate this coverage.
• If you have Part B, but are now covered under a
spouse’s employer-sponsored health insurance and
wish to voluntarily terminate this coverage.
WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS APPLICATION?
• Your Medicare number
• Your current address and phone number
• A witness and their current address and phone
number, if you signed the form with “X”
• Date you are requesting to end your premium Part A
or Part B
WHAT ARE THE CONSEQUENCES OF
DISENROLLMENT?
• If you disenroll from Part B, it may result in gaps in
your coverage, and you may incur a late enrollment
penalty of 10% for each full 12-month period you
don’t have Part B but were eligible to sign up and you
don’t have other appropriate coverage in place.
• You must have Part B while enrolled in premium
Part A. If you disenroll from Part B, your premium
Part A will also terminate.
WHAT HAPPENS NEXT?
Send your completed and signed application to your local
Social Security office. If you have questions, call Social
Security at 1-800-772-1213. TTY users should call
1-800-325-0778.
HOW DO YOU GET HELP WITH THIS
APPLICATION?
• Phone: Call Social Security at 1-800-772-1213. TTY users
should call 1-800-325-0778.
• En español: Llame a SSA gratis al 1-800-772-1213 y
oprima el 2 si desea el servicio en español y espere a
que le atienda un agente.
• In person: Your local Social Security office. For an office
near you check www.ssa.gov.
REMINDERS
If you’ve already received your Medicare card, you’ll need
to return it to the SSA office or mail it back.
WHAT IF YOU WANT TO RE-ENROLL IN
MEDICARE?
If you do not qualify for a special enrollment period (SEP),
you will need to wait until the general enrollment period
(GEP), which is every year from January—March. Coverage
will be effective the month after the month of the
enrollment request.
If you would like to re-enroll in premium Part A or Part B
you will need to complete the form CMS 18-F-5 or
CMS 40-B. If you qualify for an SEP, youll also need to
attach the following:
• If you qualify for an SEP based on employer group
health plan coverage, you’ll need to complete the
CMS L564.
• If you qualify for an SEP based on another
circumstance you’ll need to complete form CMS 10797.
• The forms will need to be provided to SSA per the
instructions on each individual form.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file
a complaint if you feel you’ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibility-nondiscrimination-
notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.