CMS-1763 Customer-Assembly Preparation Kit
This workflow helps you prepare a Medicare premium Part A, Part B, or immunosuppressive-drug coverage termination request for personal review. PostalForm prepares the official form and delivers the unsigned preparation kit only to your verified address. PostalForm does not file, serve, or submit it. After delivery, review the coverage consequences, hand-sign and date CMS-1763, contact Social Security for the required appointment or follow-up, and submit the signed request to the local office yourself.
PostalForm prepares and prints an unsigned customer-assembly kit and sends it only to your verified address. You perform final assembly and submission.
PostalForm is not affiliated with Centers for Medicare & Medicaid Services.
Need more context?
The form is ready to fill now. If you want supporting instructions, mailing notes, or source links, they are below.
Important details+
Answer the guided questions and PostalForm prepares the official form, leaves signature areas blank, adds a customer instruction cover, and sends the packet only to your verified address. Nothing is filed or submitted for you. After delivery, review the coverage consequences, hand-sign and date CMS-1763, contact Social Security for the required appointment or follow-up, and submit the signed request to the local office yourself.
What you need+
- Enrollee's name and Medicare number
- Which coverage you're ending (premium Part A, Part B, or Part B-ID) and the requested end date
- Your reason for ending coverage, in specific terms
- Current mailing address and daytime phone number
- Signature and date — two witnesses are only needed if the enrollee signs with an X mark
- Hand-sign the printed form after the preparation kit is delivered
Form summary+
This workflow helps you prepare a Medicare premium Part A, Part B, or immunosuppressive-drug coverage termination request for personal review. PostalForm prepares the official form and delivers the unsigned preparation kit only to your verified address. PostalForm does not file, serve, or submit it. After delivery, review the coverage consequences, hand-sign and date CMS-1763, contact Social Security for the required appointment or follow-up, and submit the signed request to the local office yourself.
How it works+
- Answer the guided questions and review the prepared form information.
- PostalForm prints the official form with signature areas left blank and sends the customer-assembly kit only to your verified address.
- After delivery, follow the cover instructions, hand-sign where required, and add every original, certified record, payment, witness, certification, companion form, or other physical item.
- Verify the current deadline and destination, then personally complete final submission through the official channel.
Where it gets mailed+
PostalForm mails the unsigned preparation kit to you. You complete the signatures, physical enclosures, and final submission yourself.
Packet order+
- Customer assembly instruction cover (remove and keep before final submission)
- Prepared unsigned form (signature and reserved third-party fields blank)
Common mistakes+
- Dropping Part B before confirming your new employer or union coverage is active and creditable — a coverage gap can trigger a late-enrollment penalty that usually lasts as long as you have Part B.
- Trying to drop premium-free Part A with this form — CMS-1763 only ends coverage you pay premiums for. Dropping premium-free Part A requires withdrawing your Social Security benefits application and repaying benefits.
- Not realizing that ending Part B also ends premium Part A — the acknowledgment is printed on the form itself.
- Mailing the form to Medicare or CMS instead of your local Social Security office.
- Writing a vague reason — Social Security asks for your reason in specific terms and only honors clear, signed termination requests.
FAQs+
Can I mail form CMS-1763, or do I need a Social Security interview first?
The current form's printed instructions say to send your completed, signed CMS-1763 to your local Social Security office, and Medicare's guidance says termination requests must be in writing with your signature. Social Security may still schedule a short personal interview — often by phone — to make sure you understand the consequences before processing. Mailing the signed form starts your request; you can also call 1-800-772-1213 to complete the interview proactively.
When will my Medicare coverage actually end?
Voluntary terminations generally take effect on the last day of the month after the month Social Security receives your request. For example, a request received April 5 ends coverage on May 31. You owe premiums through the termination date.
What are the risks of dropping Part B?
If you go without Part B and don't have other creditable coverage (like insurance from current employment), re-enrolling later usually adds a late-enrollment penalty of 10% of the Part B premium for each full 12-month period you went without it — and you generally pay that penalty for as long as you have Part B. You may also face a gap before coverage restarts. If you pay a premium for Part A, ending Part B automatically ends your premium Part A too, and plans that require Part B, like Medicare Advantage, end as well.
Can I use CMS-1763 to drop premium-free Part A?
No. This form only terminates coverage you pay premiums for — premium Part A, Part B, or Part B immunosuppressive drug coverage. If you get Part A premium-free, the only way to drop it is to withdraw your Social Security benefits application (form SSA-521) and repay the benefits you received, including what Medicare paid on your behalf.
How do I get Part B back after dropping it?
If you qualify for a Special Enrollment Period — for example, you stayed covered through an employer group health plan — you re-enroll with form CMS-40B plus form CMS-L564 completed by the employer. Otherwise you wait for the General Enrollment Period, January 1 to March 31 each year, with coverage starting the month after you sign up, possibly with a late-enrollment penalty.
Where do I mail form CMS-1763?
To your local Social Security office — the address is not printed on the form and there is no single national address. Find your office with the Social Security office locator at ssa.gov/locator or call 1-800-772-1213.
Sources+
Last verified+
Last Centers for Medicare & Medicaid Services verification: July 12, 2026