Updated October 18, 2026. Quick answer: Form CMS-1763 is the Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage. You can end Part B or Part B-ID at any time, and Part A only if you pay a premium for it. Part A and Part B coverage ends the last day of the month after you submit the request, and you must contact Social Security before that date if you change your mind.
Quick reference
| Item | As printed on the form or stated in Social Security’s Medicare booklet |
|---|---|
| What the form is | A request to end Medicare Part A, Part B or Part B-ID coverage |
| Part A | Can be ended only if you pay a premium for it |
| Part B and Part B-ID | Can be ended at any time |
| Where it goes | Your local Social Security office, by mail or fax |
| Reasons | Optional line on the form |
| Booklet’s late-enrollment rule | 7 months around age 65, then the January 1 to March 31 General Enrollment Period, with a 10% premium increase for each 12 months of delay (how it applies after you end Part B is a question for Social Security) |
What the form does
The form states its use in two sentences: “Use this form to request to end your Medicare coverage. You can terminate Part A only if you pay a premium for it. You can terminate Part B or Part B-ID at any time.” A person other than the enrollee can complete it, because the form has a line for the “Name of person completing this form (if not the enrollee)”.
The form asks for the enrollee’s name, Medicare number, mailing address, phone number and email address, then the coverage to end. For Part B it carries a warning: “I understand that ending Part B will also terminate my Part A if I pay a premium for Part A.”
When coverage ends
The end dates differ by coverage type. For Part A and Part B the form says “Your Part A/Part B coverage will end the last day of the month AFTER the month you submit your request. For example, if you submit your request April 5, your coverage will end May 31.”
Part B-ID is faster: “Your Part B-ID coverage will end the last day of the month you request. For example, if you ask for coverage to end in April, your last day of coverage will be April 30.” You enter the month and year you want coverage to end.
Changing your mind, and what to weigh first
The form ends its first page with a warning: “Important! If you change your mind about ending your coverage, you must contact SSA before your coverage end date.”
Ending Part B and getting it back are not symmetrical. The Social Security booklet states a late enrollment rule for people who were eligible and did not sign up: “Your monthly premium will go up 10% for each 12-month period you were eligible for Part B, but didn’t sign up for it.” The booklet’s rule is written for people who never enrolled, so ask Social Security how it would apply to you before you end coverage you may want again. Our pages on Part B premiums and switching from Medicare Advantage to Medigap cover the cost side.
Where to send it
The form says to “Mail or fax your completed, signed form to your local Social Security office.” It also asks for a witness when the form is signed with a mark: “If this form has been signed by mark (X), a witness who knows the person applying must also sign below:”
The edition read for this page is Form CMS-1763 (01/26) as the agency served it on 2026-10-18. Check the edition printed on the copy you send, because a later edition can change the questions, the mailing instructions and the evidence asked for.
Common mistakes
- Trying to end Part A when you do not pay a premium for it. The form says Part A can be terminated only if you pay a premium.
- Forgetting that ending Part B also ends a premium-paying Part A. The form makes you acknowledge it.
- Submitting on the 5th and expecting coverage to stop that month. Part A and Part B end the last day of the following month.
- Ending Part B before you have other coverage lined up. The booklet’s late-enrollment premium increase and Special Enrollment Period rules decide what getting it back costs.
Related: Form CMS-40B, the Part B penalty calculator, working past 65 and Medicare, and Social Security and Medicare forms.
Sources
- Form CMS-1763 (01/26), Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID): https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1763.pdf
- SSA Publication 05-10043 (2026), Medicare: https://www.ssa.gov/pubs/EN-05-10043.pdf
Read from the Social Security Administration and Centers for Medicare and Medicaid Services documents linked above on October 18, 2026. General information, not legal or benefits advice. Your own facts decide the outcome, and Social Security at 1-800-772-1213 is the right place to confirm anything consequential.