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.
I request termination of my enrollment under the above sections of title XVIII of the Social Security Act, as
amended, for the reason(s) stated below:
REQUEST FOR TERMINATION OF PREMIUM HOSPITAL
AND/OR SUPPLEMENTARY MEDICAL INSURANCE
Form Approved
OMB No. 0938-0025
DO NOT WRITE IN THIS SPACE
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
NAME OF PERSON, IF OTHER THAN ENROLLEE, WHO IS
EXECUTING THIS REQUEST.
THIS IS A REQUEST FOR
TERMINATION OF
■■ HOSPITAL INSURANCE
■■ MEDICAL INSURANCE
DATE SUPPLEMENTARY
MEDICAL INSURANCE
WILL END
DATE HOSITAL
INSURANCE
WILL END
If this request has been signed by mark (X), two witnesses who
know the applicant must sign below, giving their full addresses.
SIGNATURE (Write in Ink)
SIGN
HERE
1. NAME OF WITNESS
2. NAME OF WITNESS
ADDRESS
(Number and Street, City, State and Zip Code)
ADDRESS (Number and Street, City, State and Zip Code)
MAILING ADDRESS (Number and Street, City, State and Zip Code)
DATE (Month, Day and Year)
CITY, STATE, ZIP CODE
TELEPHONE NUMBER
Form CMS-1763 (05/97)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
