CMS 1763 Form


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What is Form CMS 1763?

The CMS 1763 form is also called the Request for Terminations of Premium Hospital and/or Supplementary Medical Insurance. Some people decide to cancel their insurance. The process may take some time, and you have to start by filling out the specific form for it. Since the decision is a serious step, you have to follow several steps to terminate the insurance.

Usually, before you fill out the social security form CMS 1763 you also have to talk to a person from the Social Security team. Consider it as an interview where you describe the reasons for your decision. It can be provided in person or by phone.  Once you explain your reasons, the official representative will describe the process and the results of this decision.

In case you have found a new job that covers the insurance, you have to make sure that everything works smoothly and that the primary insurance is also covered. Usually, companies prefer to cover only secondary insurance. In this case, a representative of Social Security may explain to you the options too, since Medicare stays primary.

CMS 1763 on PDFLiner

What I need the Form CMS 1763 for?

  • The most popular reason to fill out Medicare form CMS 1763 is when you or your spouse find a job that covers your health insurance. In this case, you need to make sure that you are offered a primary plan and not a secondary where Medicare remains the leading one;
  • Since your employer can’t force you to sign Medicare insurance you can opt-out and change the program up to your own preferences. Yet, you still need to have primary coverage from any other health program in this case;
  • You need form CMS-1763 in case you signed the contract with any other, non federal insurance program.

How to Fill Out Form CMS 1763?

The CMS-1763 printable form is easy to find on the Internet. You can visit the official website of the Department of Health and Human Services or go to the Medicare insurance portal. There you will be able to check out the template and learn the sections you will fill in. If you want to complete it quickly and on your device, you may open the CMS-1763 form PDF on PDFLiner.

This editing service offers all the tools you need to fill the template with your personal information. Once you enter the form, you can complete it in no time. After that, save it on your device, use the CMS-1763 form download option, print it, or send it to the other party you need. It does not take much time. The template is only one page long and does not take too much of your time. Here is what you need to indicate in it:

  1. Provide the name of the enrollee who wants to terminate the insurance, the number of Medicare insurance, name of the person who fills the request if it is different from enrollee’s;
  2. Pick the box that matches your type of request and put the tick there;
  3. Write down the date when the supplementary insurance is going to end and the date of the hospital insurance ends;
  4. Describe your situation and why you want to terminate the insurance;
  5. Ask two witnesses to sign the document on your behalf, including their names, and addresses.

CMS 1763 on PDFLiner

Organizations that work with Form CMS 1763

  • Department of Health and Human Services Centers for Medicare and Medical Services.

Where do I mail my social security form CMS 1763?

You have to complete the form in the first place. It is better to do it after the social services contact you and finish the brief interview. The filled form has to be submitted to the SSA local office. The Social Security Administration does not accept online submissions for now. Whenever you need to send it, it is better to print the document that is already filled and send to the address that was provided to you by the Social Security representative. If you did not receive the address, contact them again. Keep up with the latest news on the Medicare official website to check whether they add the ability to send the form online.

Related to CMS 1763 Form Documents

Fillable online CMS 1763 Form
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