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The completion of __________ 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.

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Answer:

CMS 1763 (Request of Termination for Premium Hospital and/ Supplementary Medical Insurance)

Explanation:

The CMS 1763 is a form that is granted to people who wish to terminate or end their premium hospital and/ medical insurance. They could either terminate the hospital insurance alone or the medical insurance alone and could also terminate both. The end dates of both insurances have to be inputted. The request is filed by writing down the name of the enrollee as well as his medical number. It could also be executed by another person other than the enrollee. You may or may not provide the reasons for termination but you have to make sure that you've fully understood the whole contract termination. It requires two witnesses who will also write down their addresses.

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