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The form CMS-1763 (attachment 5) was developed to comply with these requirements. 2. Information Users. The CMS-1763 provides CMS and SSA with the enrollee's request for termination of Part B and/or premium Part A coverage.
The completion of this 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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