Medicare cms forms cms forms items cmso17353 2026

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The document is an acknowledgment from the U.S. Department of Health and Human Services regarding a request to terminate Medicare Part A (hospital insurance) coverage. It outlines the implications of dropping this coverage, including responsibilities for premiums, options for re-enrollment, and alternative protections against medical expenses. The document emphasizes the importance of considering these factors before making a decision and provides contact information for further assistance.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the 'PRINT NAME' field. This identifies you as the requester.
Input your Social Security Number in the designated field to verify your identity.
Sign the form where indicated. If you are signing by mark, ensure a witness signs below.
Fill in the date of your signature to confirm when you completed the form.
Provide your mailing address, telephone number, city, state, and zip code for contact purposes.
If applicable, have your witness sign and provide their address to validate your signature.

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