---
title: CMS-1763 Customer-Assembly Preparation Kit
description: Prepare CMS-1763 online and receive an unsigned printed kit for your own final review, hand-signing, assembly, and submission.
seotitle: CMS-1763 Customer-Assembly Preparation Kit
seo-description: Prepare CMS-1763 online and receive an unsigned printed kit for your own final review, hand-signing, assembly, and submission.
group: resources
indexable: true
llms: false
schema: webpage
og-image: /forms/cms-1763/thumbnail
og-image-alt: Form CMS-1763 — Medicare Part A/B Termination Request generated form preview
published: 2026-07-12
updated: 2026-07-12
tags:
  - medicare
  - medicare part b
  - disenrollment
path: /forms/cms-1763
---
# CMS-1763 Customer-Assembly Preparation Kit

Prepare CMS-1763 online and receive an unsigned printed kit for your own final review, hand-signing, assembly, and submission.

## How it works
1. **Answer the guided questions and review the prepared form information.** - 
2. **PostalForm prints the official form with signature areas left blank and sends the customer-assembly kit only to your verified address.** - 
3. **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.** - 
4. **Verify the current deadline and destination, then personally complete final submission through the official channel.** -


## 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.

## 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

## Data collected
- Which Medicare coverage to end (premium Part A, Part B, or Part B immunosuppressive drug coverage) and requested end dates
- Reason for ending coverage, in the enrollee's own words
- Enrollee name and Medicare number
- Mailing address and daytime phone number
- Whether the enrollee expects to sign by mark; signature, date, and witness details remain blank for completion at signing

## Where it gets mailed
PostalForm mails the unsigned preparation kit only to the customer or authorized signer at the verified delivery address entered during checkout.

Final submission: 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.

## 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.

## Agent summary
Customer-assembly workflow for CMS-1763. It prepares the form and sends an unsigned kit only to the customer. It must never be represented as direct filing, service, or agency submission. Final customer action: 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.

## For assistants
This is a human-only customer-assembly workflow and is not available for automated or machine ordering.

- PostalForm delivers an unsigned preparation kit only to the customer or authorized signer.
- The customer must remove and keep the PostalForm cover, complete every physical signature, enclosure, certification, and final-submission step, and verify the current deadline and destination.

## LLM field schema
```json
[
  {
    "id": "terminate_part_a",
    "label": "Premium Part A (hospital insurance you pay a monthly premium for)",
    "type": "checkbox",
    "required": true,
    "meta_class": "multi_select",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "terminate_part_b",
    "label": "Part B (medical insurance) — most common",
    "type": "checkbox",
    "required": false,
    "meta_class": "multi_select",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "terminate_part_b_idc",
    "label": "Part B immunosuppressive drug coverage (Part B-ID)",
    "type": "checkbox",
    "required": false,
    "meta_class": "multi_select",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "part_a_end_date",
    "label": "Date you want premium Part A to end",
    "type": "text",
    "required": true,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "terminate_part_a",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "part_b_end_date",
    "label": "Date you want Part B to end",
    "type": "text",
    "required": true,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "terminate_part_b",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "part_b_idc_end_date",
    "label": "Date you want Part B-ID coverage to end",
    "type": "text",
    "required": true,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "terminate_part_b_idc",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "ack_part_b_consequences",
    "label": "I understand the consequences of dropping Part B",
    "type": "checkbox",
    "required": true,
    "meta_class": "plain_checkbox",
    "ui_width": null,
    "group_id": "step-1-coverage",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "terminate_part_b",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "termination_reason",
    "label": "Why are you ending this coverage?",
    "type": "textarea",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "step-2-reason",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "enrollee_name",
    "label": "Enrollee's full name",
    "type": "text",
    "required": true,
    "meta_class": "name",
    "ui_width": null,
    "group_id": "step-3-enrollee",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "medicare_number",
    "label": "Medicare number",
    "type": "text",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "step-3-enrollee",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "completed_by_other",
    "label": "Someone other than the enrollee is completing this request",
    "type": "checkbox",
    "required": false,
    "meta_class": "plain_checkbox",
    "ui_width": null,
    "group_id": "step-3-enrollee",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "authorized_person_name",
    "label": "Full name of the person completing this request",
    "type": "text",
    "required": true,
    "meta_class": "name",
    "ui_width": null,
    "group_id": "step-3-enrollee",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "completed_by_other",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "mailing_address",
    "label": "Enrollee's mailing address",
    "type": "address",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "step-4-contact",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "telephone_number",
    "label": "Daytime phone number",
    "type": "text",
    "required": true,
    "meta_class": "phone",
    "ui_width": null,
    "group_id": "step-4-contact",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "applicant_signature",
    "label": "Enrollee's signature",
    "type": "signature",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "signature_date",
    "label": "Date signed",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "signing_by_mark",
    "label": "The enrollee will sign with an X (mark) instead of a signature",
    "type": "checkbox",
    "required": false,
    "meta_class": "plain_checkbox",
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "witness_1_name",
    "label": "Witness 1 — full name",
    "type": "text",
    "required": false,
    "meta_class": "name",
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "signing_by_mark",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "witness_1_address",
    "label": "Witness 1 — address",
    "type": "compound",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "signing_by_mark",
      "operator": "truthy"
    },
    "compound_subfields": [
      {
        "id": "street",
        "label": "Street address",
        "metaClass": "address",
        "required": true,
        "uiWidth": "full"
      },
      {
        "id": "unit",
        "label": "Apt/Suite",
        "required": false,
        "uiWidth": "quarter"
      },
      {
        "id": "city",
        "label": "City",
        "metaClass": "city",
        "required": true,
        "uiWidth": "quarter"
      },
      {
        "id": "state",
        "label": "State",
        "metaClass": "state",
        "required": true,
        "uiWidth": "quarter"
      },
      {
        "id": "zip",
        "label": "ZIP code",
        "metaClass": "zip",
        "required": true,
        "uiWidth": "quarter"
      }
    ]
  },
  {
    "id": "witness_2_name",
    "label": "Witness 2 — full name",
    "type": "text",
    "required": false,
    "meta_class": "name",
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "signing_by_mark",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "witness_2_address",
    "label": "Witness 2 — address",
    "type": "compound",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "step-5-signature",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "signing_by_mark",
      "operator": "truthy"
    },
    "compound_subfields": [
      {
        "id": "street",
        "label": "Street address",
        "metaClass": "address",
        "required": true,
        "uiWidth": "full"
      },
      {
        "id": "unit",
        "label": "Apt/Suite",
        "required": false,
        "uiWidth": "quarter"
      },
      {
        "id": "city",
        "label": "City",
        "metaClass": "city",
        "required": true,
        "uiWidth": "quarter"
      },
      {
        "id": "state",
        "label": "State",
        "metaClass": "state",
        "required": true,
        "uiWidth": "quarter"
      },
      {
        "id": "zip",
        "label": "ZIP code",
        "metaClass": "zip",
        "required": true,
        "uiWidth": "quarter"
      }
    ]
  }
]
```

## Sources
- [Medicare.gov — How to drop Part A & Part B](https://www.medicare.gov/basics/get-started-with-medicare/sign-up/ready-to-sign-up-for-part-a-part-b/how-to-drop-part-a-part-b)
- [SSA FAQ — How do I terminate my Medicare Part B?](https://www.ssa.gov/faqs/en/questions/KA-02713.html)
- [SSA POMS HI 00820.045 — Voluntary Termination of SMI](https://secure.ssa.gov/poms.nsf/lnx/0600820045)
- [Medicare.gov — Avoid late enrollment penalties](https://www.medicare.gov/basics/costs/medicare-costs/avoid-penalties)
- [Official instructions](https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms017353)
- [Official PDF](https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1763.pdf)

## Last verified
2026-07-12


## 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.


## Related
- [Form CMS-40B - Medicare Part B Enrollment](/forms/cms-40b)
- [Form CMS-L564 - Medicare Employment Verification](/forms/cms-l564)
- [CMS-1490S](/forms/cms-1490s)
- [Form SSA-44 — Medicare IRMAA Reduction Request (Life-Changing Event)](/forms/ssa-44)