Fill Out Form CMS-1763, Request for Termination of Medicare Coverage

Stop guessing which parts of Medicare you want to end or missing fields. Upload your CMS‑1763 PDF, answer simple questions about your enrollee details, coverage, and effective dates, and Simplicity AI fills every field accurately. Review, sign, and export a clean form ready to submit.

AI converts the CMS-1763 into an interactive form. No manually tapping into dense government fields or second-guessing which sections apply to Part A versus Part B termination.

Dropping Part A, Part B, or both? AI shows only the fields and acknowledgment statements relevant to the coverage you're terminating, so you're not reading through sections that don't apply to your situation.

AI flags the consequences of disenrollment before you sign: potential repayment of Part A benefits, late enrollment penalties for Part B re-enrollment, and coverage gaps. No surprises after you submit.

Form INFORMATIONS

Beneficiary's Name

Your full legal name as it appears on your Medicare card and Social Security records. If your name has changed due to marriage, divorce, or legal name change and you haven't updated it with Social Security, do that first. A mismatch between your CMS-1763 and Medicare's records can delay processing or result in the wrong person's coverage being terminated.

Beneficiary's Medicare Claim Number

The number on your red, white, and blue Medicare card. If you have a newer card, your Medicare Beneficiary Identifier (MBI) is an 11-character alphanumeric code. If you still have an older card, it's your Health Insurance Claim Number (HICN). This connects your termination request to your specific Medicare enrollment record.

Beneficiary's Date of Birth

Your date of birth as recorded by Social Security. This serves as a secondary identifier to ensure the termination request is applied to the correct beneficiary, especially when names or claim numbers require additional verification.

Beneficiary's Address and Phone Number

Your current mailing address and daytime phone number. Social Security uses this to confirm your disenrollment and contact you if they need additional information before processing your request. Make sure this reflects your current mailing address, not an outdated address from a prior enrollment.

Coverage Being Terminated

Whether you're requesting termination of Medicare Part A (Hospital Insurance), Part B (Medical Insurance), or both. This is the most critical field because the consequences differ significantly. Terminating Part A may require repayment of all benefits received since enrollment. Terminating Part B means a 10% late enrollment penalty for every 12-month period you go without coverage if you ever re-enroll. Simplicity AI explains the implications of each option before you make your selection.

Reason for Termination

Why you're requesting disenrollment. Common reasons include dropping Part A to maintain HSA contribution eligibility, ending Part B because you have employer or union coverage you prefer, or terminating coverage due to religious or personal objections to government insurance. The reason you provide helps Social Security process the request and may determine what additional documentation is required.

Effective Date of Termination

The date you want your Medicare coverage to end. This determines the last day Medicare will pay for your medical services. If you're dropping Part A to preserve HSA eligibility, the effective date must align with the date your HSA contributions began or will begin. If you're dropping Part B because employer coverage is active, the effective date should be set to avoid a gap between when Part B ends and your employer plan coverage begins.

Acknowledgment of Consequences

A series of statements confirming that you understand what happens when your Medicare coverage is terminated. For Part A: you may be required to repay all Medicare benefits paid on your behalf since enrollment, and re-enrollment is only available during the General Enrollment Period (January through March each year), with coverage not starting until July. For Part B: you'll face a permanent 10% premium penalty for every 12-month period you were eligible but not enrolled if you re-enroll later. Simplicity AI surfaces each applicable consequence based on the coverage you're terminating, so you fully understand the decision before signing.

Beneficiary Signature and Date

Your signature confirming that you're voluntarily requesting termination, that you understand the consequences, and that the information provided is accurate. This must be your own signature. If someone is completing the form on your behalf (a legal guardian, authorized representative, or power of attorney), they sign with their authority noted and may need to provide separate authorization documentation.

Representative Information (if applicable)

If an authorized representative is filing on your behalf, their name, address, phone number, and relationship to you. Social Security may require additional proof of authorization, such as a court order, a power of attorney, or Form SSA-1696, before processing a termination request submitted by someone other than the beneficiary.

Where to Submit

The form is submitted to your local Social Security office. Once processed, the termination is final unless you re-enroll during an eligible enrollment period, subject to any applicable penalties and waiting periods.

WHAT IS FORM CMS-1763?

What Is Form CMS-1763 and Who Needs to Fill It Out?

Form CMS-1763, officially called "Request for Termination of Medicare Coverage," is the official Social Security Administration form used to voluntarily withdraw from Medicare Part A, Part B, or both. It informs Social Security that you've decided to end your Medicare coverage, that you understand the consequences, and that you authorize them to process the disenrollment. The form doesn't cancel your coverage automatically. Social Security reviews it, confirms your acknowledgment of the penalties and repayment obligations, and then processes the termination.

Unlike calling Medicare or visiting your local Social Security office to ask questions about your options, Form CMS-1763 is the official written request that initiates disenrollment. Once processed, the termination is final unless you re-enroll during an eligible enrollment period, subject to applicable penalties and waiting periods. You may need a CMS-1763 if: you're dropping Medicare Part A to preserve HSA contribution eligibility (IRS rules prohibit HSA contributions once enrolled in any part of Medicare); you have employer or union group health coverage you prefer over Part B and want to stop paying the Part B premium; you enrolled in Medicare but want to reverse the decision before it affects your benefits or tax situation; your circumstances have changed and maintaining Medicare is no longer advantageous; or you have a religious, conscientious, or personal objection to government-provided health insurance.

The form includes beneficiary details, coverage selection, reason for termination, and acknowledgments. Terminating Part A may require repaying every Medicare benefit paid on your behalf since enrollment. Terminating Part B triggers a permanent 10% premium penalty for every 12-month period you were eligible but not enrolled if you ever re-enroll. Once the form is processed, there's no quick undo. That's where Simplicity AI comes in.

How to Fill Out Your CMS-1763 Online in 6 Simple Steps

Upload your CMS-1763 PDF to Simplicity AI. The AI scans every section of the form and converts it into a guided, interactive questionnaire.

Enter your full legal name, Medicare claim number, date of birth, and current mailing address and phone number.

Select the coverage you're terminating: Medicare Part A, Part B, or both. AI explains the consequences of each option before you commit to a selection.

Enter your reason for termination and your requested effective date. AI checks that the date aligns with your situation, whether that's preserving HSA eligibility, transitioning to employer coverage, or another qualifying reason.

Review the acknowledgment statements. AI surfaces the specific consequences that apply to your selection: benefit repayment for Part A, late enrollment penalties for Part B, or both.

Review every field for accuracy, sign electronically, and download your completed CMS-1763 as a clean PDF ready to submit to your local Social Security office.

Super Fast

Complete your CMS-1763 in minutes. No deciphering government language or guessing which acknowledgment statements apply to Part A versus Part B termination.

AI-Powered

Simplicity AI understands the CMS-1763's structure, from coverage selection through consequence acknowledgments. It shows only the sections relevant to the coverage you're dropping, so you know exactly what you're agreeing to before you sign.

Secure

Your CMS-1763 contains sensitive data, including your Medicare claim number, date of birth, and the reason you're terminating coverage. Documents are encrypted, handled privately, and never shared. Your data stays yours.

FAQs

Frequently Asked Questions About Form CMS-1763

What is Form CMS-1763, and why would I need to fill it out?

Form CMS-1763 is the official Social Security Administration form for voluntarily terminating Medicare Part A, Part B, or both. You'd need to fill it out if maintaining Medicare coverage creates a conflict with other benefits (like HSA contributions), if you have employer coverage you prefer over Part B, or if your financial or personal circumstances make disenrollment the better option. It's a serious decision with long-term consequences, which is why the form includes acknowledgments of penalties and repayment obligations.

How do I fill out Form CMS-1763 online for free?

You can fill out Form CMS-1763 online for free using Simplicity AI. Our platform converts the PDF into a guided questionnaire that walks you through each section, from beneficiary details to the consequence acknowledgments. Simply visit our website, upload your CMS-1763 PDF, and follow the prompts to complete your form in minutes.

If I drop Medicare Part A, do I have to repay benefits?

Yes. If you voluntarily terminate Part A, Social Security may require you to repay all Medicare benefits that were paid on your behalf since your enrollment began. This includes hospital stays, skilled nursing facility care, home health services, and hospice care that Medicare covers. The repayment obligation is one of the most significant consequences of Part A termination, which is why most people pursue this option only when the financial benefit of maintaining HSA eligibility outweighs the repayment amount.

What happens if I drop Part B and want to re-enroll later?

You'll face a permanent late enrollment penalty. Medicare adds 10% to your monthly Part B premium for every 12-month period you were eligible but not enrolled. That penalty applies for as long as you have Part B. You can only re-enroll during the General Enrollment Period (January through March each year), and coverage won't start until July 1. That means you could have a gap of several months without Part B coverage and no way to expedite the process.

Can I drop Part A to keep contributing to my HSA?

Yes, and this is the most common reason people file Form CMS-1763 for Part A termination. IRS rules prohibit HSA contributions once you're enrolled in any part of Medicare, including premium-free Part A. If you're still working and want to continue contributing to your HSA, you need to formally terminate Part A using the CMS-1763. Keep in mind that dropping Part A also means giving up Part A benefits and potentially repaying benefits already received.

Can I terminate just Part B and keep Part A?

Yes. You can terminate Part A, Part B, or both independently. Many people keep Part A (which is premium-free for most beneficiaries) and drop Part B to stop paying the monthly premium while they have employer coverage. Simplicity AI shows only the acknowledgment statements and consequence disclosures relevant to the specific coverage you're terminating, so you're not reading through sections that don't apply.

Where do I submit the completed CMS-1763?

You submit the completed form to your local Social Security office, either in person, by mail, or by fax. Unlike Medicare enrollment forms that go through CMS directly, the CMS-1763 is processed by Social Security, which manages Medicare enrollment records. Simplicity AI exports a clean PDF ready to submit through whichever method is most convenient for you.

Is my data safe when filling out Form CMS-1763 on Simplicity AI?

Yes. Your CMS-1763 contains sensitive information, including your Medicare claim number, date of birth, and the reason you're terminating coverage. Simplicity AI encrypts all documents, handles your data privately, and never shares it with third parties. Your data stays yours.

Common Mistakes in Completing Form CMS-1763

Terminating Part A Without Calculating the Repayment Obligation

When you drop Part A, Social Security can require you to repay every Medicare benefit paid on your behalf since enrollment. That includes hospital stays, skilled nursing care, home health services, and hospice. If you've had a single hospitalization in the past few years, the repayment amount could be tens of thousands of dollars. Many people file the CMS-1763 to preserve HSA eligibility without first adding up what Medicare has already paid. Simplicity AI flags the repayment consequence before you select Part A termination, so you can make the calculation before you commit.

Dropping Part B Without Understanding the Permanent Penalty

The Part B late enrollment penalty isn't a one-time fee. It's a 10% surcharge added to your monthly premium for each 12-month period you were eligible but not enrolled, and it remains in effect for the rest of your life. If you drop Part B for three years and re-enroll, you'll pay 30% more than the standard premium every month, permanently. Some people assume they can drop and re-add Part B freely. You can't. Simplicity AI calculates what your penalty would look like based on how long you plan to go without coverage.

Not Confirming Alternative Coverage Before Terminating

Some beneficiaries file the CMS-1763, assuming their employer plan or spouse's plan will cover everything Medicare was covering. But employer plans and Medicare cover different things at different rates. If your employer plan has higher deductibles, limited hospital coverage, or doesn't cover services Medicare would have, you could end up paying more out of pocket than you saved by dropping the premium. Verify your alternative coverage fills the gap before you submit the form.

Using the Wrong Effective Date

The effective date of termination determines the last day Medicare pays for your care. If you're dropping Part A to start HSA contributions, the effective date must align with the start date of those contributions. If you're dropping Part B because employer coverage is active, the effective date shouldn't create a gap between when Part B ends and when your employer plan covers you. Even a one-day gap can result in uncovered medical expenses. Simplicity AI prompts you to confirm your alternative coverage start date against your requested termination date.

Confusing COBRA or Retiree Coverage with Active Employer Coverage

If you're dropping Part B because you think your employer coverage makes it unnecessary, make sure it's coverage based on current, active employment. COBRA continuation coverage and retiree health plans do not qualify you for a Special Enrollment Period if you later want to re-enroll in Part B without penalties. If you terminate Part B while on COBRA and the COBRA runs out, you'll wait until the next General Enrollment Period and pay the late penalty. Simplicity AI asks whether your coverage is based on active employment or a continuation plan, so you don't make an irreversible decision based on temporary insurance.

Filing Without Reading the Acknowledgment Statements

The CMS-1763 includes specific acknowledgment statements about what happens when your coverage ends. These aren't boilerplate. They describe repayment obligations for Part A, permanent premium penalties for Part B, re-enrollment restrictions, and potential coverage gaps. Signing without understanding these statements means you've legally acknowledged consequences you may not have actually considered. Simplicity AI surfaces each acknowledgment in plain English based on the coverage you're terminating and requires you to confirm each one individually before generating the signature page.

Submitting the Form to the Wrong Office

The CMS-1763 goes to your local Social Security office, not to Medicare, not to CMS, and not to your insurance company. Sending it to the wrong place doesn't terminate your coverage. It just delays the process while you continue paying premiums or accumulating benefits you may later have to repay. Simplicity AI confirms the correct submission method (in person, by mail, or by fax to your local Social Security office) before you export the final PDF.

Assuming the Termination Can Be Easily Reversed

Once Social Security processes your CMS-1763, the disenrollment is final. You can't call and undo it. For Part A, re-enrollment is available only during the General Enrollment Period (January through March), with coverage starting on July 1. For Part B, the same enrollment window, same July start date, plus the permanent penalty. If you terminate in April and change your mind in May, you'll be without coverage for over a year and face a penalty when you return. Simplicity AI makes the permanence of this decision clear at every step, so there are no surprises after submission.

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