Form CMS-1763, Request for Termination of Premium Medicare
Dropping Medicare Part B is deliberately not casual: Form CMS-1763 is the formal termination request, usually completed alongside a conversation with Social Security about the consequences.
This is the genuine CMS PDF, unmodified. Source: CMS official page.
What is CMS-1763?
Form CMS-1763 requests voluntary termination of premium Medicare coverage, most often Part B, sometimes premium Part A. People file it when returning to employer coverage that makes the Part B premium wasteful, or when other arrangements cover them. SSA generally wants a personal interview before processing, precisely so no one drops coverage without understanding re-enrollment penalties and waiting periods.
Coverage ends prospectively based on when the request is filed, and premiums stop with it. Re-enrolling later may mean waiting for an enrollment period and, without qualifying coverage in between, a late enrollment penalty.
Who files CMS-1763?
- Beneficiaries returning to work with employer group coverage
- People paying premium Part A or Part B they no longer want
- Not for switching Medicare Advantage or Part D plans, which have their own processes
How to fill out CMS-1763
- Contact Social Security first; the termination interview is standard and books the decision on the record.
- Fill in your name, Medicare claim number, and the coverage you want ended.
- State the requested termination date and sign the acknowledgment of consequences.
- Download, sign, and submit it to your Social Security office as instructed after the interview.
Quick fill CMS-1763 on this page
Prefer to see the form itself while you type? Open CMS-1763 in the editor to fill it on the actual pages, add a signature, and download.
Frequently asked questions
Why does SSA insist on an interview?
Because dropping Part B without other qualifying coverage triggers a lifetime penalty on any later re-enrollment and can leave a coverage gap; SSA is required to make sure that is understood.
Can I get Part B back later?
Yes, but generally only during an enrollment period, and with a premium penalty unless you had employer coverage in the meantime that qualifies you for a Special Enrollment Period.