Completing Form CMS-1763
How to Complete Form CMS-1763
Form CMS-1763 is used to voluntarily terminate Premium-Part A or Voluntary Part B Medicare coverage. This is a serious decision — talk with Fred before submitting.
Download Form CMS-1763
What Is Form CMS-1763?
Form CMS-1763 is the official Medicare form used to request the voluntary termination of:
- Premium-Part A coverage (for those who pay a premium for Part A)
- Voluntary Part B coverage (Medical Insurance)
Most Medicare beneficiaries have premium-free Part A and do not pay a premium for it. This form is most commonly used by people who want to drop Part B — for example, because they are returning to employer group health coverage that will serve as their primary insurance.
This Is a Serious, Difficult-to-Reverse Decision
Dropping Part B is generally only allowed during the General Enrollment Period (January 1 – March 31) each year, with coverage ending the following July 1. Re-enrolling later may result in a permanent late enrollment penalty added to your Part B premium. Please speak with Fred before submitting this form.
When Would You Use This Form?
- You enrolled in Part B but are returning to active employer group health coverage that will be primary
- You pay a premium for Part A and no longer want or need that coverage
- You have been advised by a benefits counselor that dropping Part B is appropriate for your situation
- You are enrolled in a retiree health plan that requires you to drop Medicare Part B
How to Complete CMS-1763
Section 1 – Beneficiary Information
- Full legal name as it appears on your Medicare card
- Medicare Beneficiary Identifier (MBI) — the 11-character ID on your red, white, and blue card
- Date of birth
- Current mailing address and phone number
Section 2 – Coverage to Be Terminated
- Check the box for Premium-Part A, Voluntary Part B, or both
- Indicate the requested termination date (SSA will confirm the effective date)
- Provide the reason for termination (e.g., returning to employer coverage)
Section 3 – Signature and Certification
- Sign and date the form — your signature confirms you understand the consequences
- If signing on behalf of the beneficiary, provide your relationship and authority (e.g., Power of Attorney)
Where to Submit
Form CMS-1763 must be submitted to the Social Security Administration (SSA) — not directly to Medicare or CMS.
- Mail to your local Social Security Administration office
- Deliver in person to a Social Security office
- Call SSA at 1-800-772-1213 to ask about fax or online options
Talk to Fred Before You Submit
Dropping Medicare Part B is one of the most consequential decisions a Medicare beneficiary can make. Fred can review your specific situation — including your employer coverage, income, and long-term plans — to make sure this is the right move before you submit the form.