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The document is a form from the Department of Health and Human Services, specifically the Centers for Medicare & Medicaid Services, used to request the termination of Medicare coverage. It outlines the necessary information required from the enrollee, including their name, Medicare claim number, and the specific insurance coverage being terminated. The form emphasizes that termination of supplementary medical insurance will also affect hospital insurance coverage and provides instructions for completion and submission.

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2022	4.6 Satisfied (34 Votes)
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Can I submit form CMS 1763 online?

You have to submit Form CMS-1763 by mail or fax.

Can I submit CMS 1763 online?

Can you submit form CMS-1763 online? No. You have to submit Form CMS-1763 by mail or fax.

What is CMS 1763?

CMS 1763. Form Title. Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance.

Can I submit my Medicare Part B application online?

You can complete your Medicare Part B Enrollment online. You will electronically sign the online application, so you will need to provide an email address.

How to fill CMS 1763?

How to fill out Form CMS 1763? Name of Enrollee. Medicare Number. Name of the Person, if Other than Enrollee, Who Is Executing the Request (if appropriate). This is a Request for Termination of Hospital Insurance/Medical Insurance. Date Hospital Insurance Will End. Reasons for the termination request.