Request For Termination Of Premium Hospital And/or Supplementary Medical Insurance (Form Cms-1763)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0025

DO NOT WRITE IN THIS SPACE

REQUEST FOR TERMINATION OF PREMIUM HOSPITAL

AND/OR SUPPLEMENTARY MEDICAL INSURANCE

The completion of this form is needed to document your voluntary request for termination of

Medicare coverage as permitted under the Code of Federal Regulations. Section 1838(b) and

1818A(c)(2)(B) of the Social Security Act require filing of notice advising the Administration when

termination of Medicare coverage is requested. While you are not required to give your reasons for

requesting termination, the information given will be used to document your understanding of the

effects of your request.

NAME OF ENROLLEE (Please Print)

MEDICARE CLAIM NUMBER

DATE SUPPLEMENTARY

NAME OF PERSON, IF OTHER THAN ENROLLEE, WHO IS

THIS IS A REQUEST FOR

DATE HOSPITAL

MEDICAL INSURANCE WILL

EXECUTING THIS REQUEST.

TERMINATION OF

INSURANCE WILL END

END

MEDICAL INSURANCE

HOSPITAL INSURANCE

I request termination of my enrollment under the above section(s) of title XVIII of the Social Security Act, as amended, for

the reason(s) stated below:

I UNDERSTAND THAT IF I AM REQUIRED TO PAY FOR MY HOSPITAL INSURANCE, THE TERMINATION OF MY SUPPLEMENTARY MEDICAL INSURANCE

COVERAGE WILL ALSO END MY HOSPITAL INSURANCE COVERAGE.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of

information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0025. The time required to complete this information

collection is estimated to average 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the

information collection. If you have any comments concerning the accuracy of the estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance

Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

If this request has been signed by mark (X), two witnesses who

SIGNATURE (Write in Ink)

know the applicant must sign below, giving their full addresses.

SIGN

1. NAME OF WITNESS

HERE

ADDRESS

MAILING ADDRESS

(Number and Street, City, State and Zip Code)

(Number and Street)

CITY, STATE, ZIP CODE