What is Form CMS-1763?
Form CMS-1763 is how you ask Social Security to end Medicare coverage you've chosen to stop: Part B (Medical Insurance), Part A (Hospital Insurance) if you pay a premium for it, or Part B-ID, the immunosuppressive drug coverage for people whose other Medicare ended after a kidney transplant. The form says you can terminate Part B or Part B-ID at any time, and Part A only if you pay a premium for it.
It's a one-page form: your name and Medicare Number, mailing address, phone and email, the name of anyone completing it for you, and a box for each part you want to end. Ending Part B comes with an acknowledgement that it also ends premium Part A. For Part B-ID you choose the month and year coverage should end. There's an optional space for your reasons, then your signature and date, and a witness section for someone who signs by mark (X).
FileIt guides you through it, splits your Medicare Number, phone and dates into the form's little boxes, and prints everything onto CMS's own PDF (CMS-1763, 01/26). You can sign with eSignature or by hand. FileIt keeps a copy in your vault but never sends it: you mail or fax it to Social Security yourself.
- Who fills it
- A person with Medicare who wants to end Part B, premium Part A or Part B-ID (or someone helping them).
- Sent to
- Your local Social Security office, by mail or fax (SSA.gov/locator).
- Part A and Part B end
- The last day of the month after the month you submit the request.
- Part B-ID ends
- The last day of the month you choose on the form.
- Signatures
- The enrollee signs and dates it; a witness also signs if it's signed by mark (X).
- Edition
- CMS-1763 (01/26), OMB No. 0938-0025, expires 08/31/2027
Who needs to fill out Form CMS-1763?
- People who've gone back to work and are now covered by an employer's group health plan, and want to stop paying the Part B premium.
- People who bought premium Part A and no longer want it.
- Part B-ID enrollees who now have other coverage for their immunosuppressive drugs.
- Family members or representatives completing the form for someone with Medicare.
When to use Form CMS-1763
- When you've decided to drop Part B, premium Part A or Part B-ID, and know when you want it to end.
- A month ahead for Part A or Part B: the form says coverage ends the last day of the month after the month you submit it.
- For Part B-ID, whenever you're ready: you pick the end month.
- After checking your other coverage, since going without Part B and enrolling later can mean a late enrollment penalty.
What you need before you start
- Your name as on your Medicare card, and your 11-character Medicare Number.
- Your mailing address, phone number and (optionally) email.
- Which coverage you want to end: Part A (premium only), Part B, Part B-ID.
- For Part B-ID, the month and year you want coverage to end.
- Your reasons, if you'd like to give them (optional).
- A witness, only if you'll sign with a mark (X).
What’s on Form CMS-1763
The 2026 edition has 2 pages. FileIt asks for it in 3 parts, and it is signed by Enrollee (person with medicare):
- About youEnrollee (person with medicare)
- What you want to endEnrollee (person with medicare)
- Witness (only if you sign with a mark)Witness
How to fill out Form CMS-1763, step by step
1 About you
Enter your first, middle and last name and any suffix, your Medicare Number, mailing address, phone and email. If someone else is completing the form for you, give their name.
2 Part A
Tick Part A only if you pay a premium for it. Premium-free Part A can't be ended with this form.
3 Part B
Tick Part B to end it, and confirm you understand that ending Part B also ends your Part A if you pay a premium for Part A.
4 Part B-ID
Tick Part B-ID and give the month and year you want it to end. Your last day of coverage is the last day of that month.
5 Reasons and signature
Add your reasons if you want to (optional). Then sign and date the form, by hand or with eSignature.
6 Signing by mark
If you sign with an X, a witness who knows you must also sign and date the form. FileIt prints the witness's name; the witness signs by hand.
Common mistakes to avoid
- Trying to end premium-free Part A: the form only ends Part A that you pay a premium for.
- Forgetting that ending Part B also ends premium Part A.
- Leaving out the Part B-ID end month.
- Writing the Medicare Number with letters the number never uses (S, L, O, I, B, Z) instead of the numbers 0 and 1.
- Expecting coverage to stop the same day: Part A and Part B end on the last day of the month after you submit.
- Changing your mind and not contacting Social Security before the coverage end date.
After you fill it out
Sign and date the form, then mail or fax it to your local Social Security office. Keep a copy and note the date you sent it.
The form says that if you change your mind, you must contact Social Security before your coverage end date.
Keep the filed request and any confirmation from Social Security in your FileIt vault with your Medicare card and other benefit records.
Fill out Form CMS-1763 online with FileIt
- Pick the person. Choose someone from People and FileIt fills in their name, date of birth, address and other details it already knows.
- Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 19 fields in all. Your answers save as you go.
- Check the live preview. Watch your answers land on the real Centers for Medicare & Medicaid Services (CMS) form, and let FileIt do any worksheet arithmetic.
- Generate the official PDF. FileIt prints your answers into the agency’s own PDF and files it in that person’s folder in your vault. Sign it, or send it for e-signature.
FileIt fills the form — it never files or submits anything for you. Deliver the finished form to whoever asked for it, the way the form’s instructions say.
Start Form CMS-1763 now — it’s freeForm CMS-1763: frequently asked questions
How do I cancel Medicare Part B?
Complete Form CMS-1763, tick Part B, confirm the acknowledgement about premium Part A, sign it, and mail or fax it to your local Social Security office.
When does my Part B stop?
The form says Part A and Part B coverage ends the last day of the month after the month you submit your request. For example, a request submitted April 5 ends coverage May 31.
Can I end premium-free Part A?
The form says you can terminate Part A only if you pay a premium for it.
What is Part B-ID?
Part B immunosuppressive drug coverage, for people whose Medicare ended after a kidney transplant. With CMS-1763 you choose the month it ends.
Can someone fill this out for me?
Yes. The form has a box for the name of the person completing it if that's not the enrollee. The enrollee still signs, or signs by mark with a witness.
Can I sign CMS-1763 electronically?
FileIt can place your signature and date with eSignature, or you can print and sign by hand. A witness for a signature by mark signs by hand.
Does FileIt send the form to Social Security?
No. FileIt prepares the official PDF and keeps a copy in your vault. You mail or fax it to Social Security yourself.
Official sources
- Blank form (PDF), published by Centers for Medicare & Medicaid Services (CMS): https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1763.pdf
- Official instructions and guidance: https://www.cms.gov/medicare/forms-notices/cms-forms-list
- Edition shown on this page: CMS-1763 (01/26), OMB No. 0938-0025, expires 08/31/2027 (checked 2026-10-19).
FileIt is not affiliated with or endorsed by Centers for Medicare & Medicaid Services (CMS) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-19.