Enrollee information
First, middle and last name, suffix, Medicare Number, mailing address, city, state, ZIP code, phone number and email address.
CMS-1763
Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance
- Agency
- CMS
- Revision
- 01/26
- Fillable fields
- 29
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-1763: Request for Termination of Medicare Premium Part A, Part B, or Part B-ID
Form CMS-1763 is the Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID) from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The form says to use it to request to end your Medicare coverage. It says Part A can be ended only if you pay a premium for it, and Part B or Part B-ID can be ended at any time.
The one-page form asks for the enrollee's name, Medicare Number, mailing address, phone and email, the name of anyone completing it for the enrollee, which coverage to end, optional reasons, and a signature, with a witness if it is signed by mark (X). Notes on the form explain when each kind of coverage ends.
The completed, signed form goes to your local Social Security office by mail or fax. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-1763
Person completing the form
The name of the person completing this form, if it is not the enrollee.
Coverage to end
Boxes for Part A (Hospital Insurance), Part B (Medical Insurance) and Part B-ID, with a field for the month and year you want Part B-ID coverage to end.
When coverage ends
Notes say Part A or Part B coverage ends the last day of the month after the month you submit the request, and Part B-ID coverage ends the last day of the month you request.
Reasons and signatures
Optional reasons for ending coverage, the signature and date signed (mm/dd/yyyy), and the witness name, signature and date if the form is signed by mark (X).
How to submit Form CMS-1763
- 1
Check which coverage can end
The form says Part A can be ended only if a premium is paid for it, while Part B and Part B-ID can be ended at any time.
- 2
Fill in the enrollee details
Enter the enrollee's name, Medicare Number, mailing address, phone and email, and the name of the person completing the form if it is not the enrollee.
- 3
Choose the coverage to end
Check Part A, Part B or Part B-ID. For Part B-ID, enter the month and year you want coverage to end.
- 4
Add reasons if you want
The form marks the reasons for ending Medicare coverage as optional.
- 5
Sign and date it
Sign and enter the date signed. A form signed by mark (X) also needs a witness's name, signature and date.
- 6
Send it to Social Security
Mail or fax the completed, signed form to your local Social Security office. Find an office at SSA.gov/locator.
Why fill Form CMS-1763 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, end dates and help
Where to send it
To your local Social Security office by mail or fax. Find an office at SSA.gov/locator. The CMS address on page 2 is for comments on the time estimate and the form, not for requests.
When Part A or Part B ends
The last day of the month after the month you submit the request. The form's example: a request submitted April 5 ends coverage May 31.
When Part B-ID ends
The last day of the month you request. The form's example: asking for coverage to end in April makes April 30 the last day of coverage.
Changing your mind
The form says that if you change your mind about ending coverage, contact SSA before your coverage end date.
Time to complete
The form estimates an average of 10 minutes per response, including reviewing instructions and gathering the information.
Related forms
CMS-40B
Request for Enrollment in Medicare Part B (Medical Insurance)
47 fields, 3 pages
CMS-10798
Application for Enrollment in Part B Immunosuppressive Drug Coverage
32 fields, 3 pages
CMS-L564
Medicare Request for Employment Information
45 fields, 2 pages
CMS-10106
1-800-Medicare Authorization to Disclosure Personal Health Information
44 fields, 3 pages
CMS-1490S
PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
49 fields, 18 pages
CMS-20027
MEDICARE REDETERMINATION REQUEST FORM
20 fields, 1 page
Who uses Form CMS-1763?
The form is for people who want to end certain Medicare coverage. It says which coverage can be ended and when.
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Questions about Form CMS-1763
Can I end Medicare Part A with Form CMS-1763?
Only premium Part A. The form says you can terminate Part A only if you pay a premium for it.
When does my coverage end?
The form says Part A or Part B ends the last day of the month after the month you submit the request, for example May 31 for a request submitted April 5. Part B-ID ends the last day of the month you request.
Does ending Part B affect Part A?
The form says ending Part B also terminates Part A if you pay a premium for Part A.
Where do I send Form CMS-1763?
The form says to mail or fax the completed, signed form to your local Social Security office. Find an office near you at SSA.gov/locator.
What if I change my mind?
The form says to contact SSA before your coverage end date if you change your mind about ending your coverage.
Do I have to give a reason?
No. The form marks the reasons for ending Medicare coverage as optional.
Can someone fill out Form CMS-1763 for me?
The form has a field for the name of the person completing it, if not the enrollee. If the form is signed by mark (X), a witness who knows the person also signs and dates it.