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What you should know about CMS 1763 1997 Form

  1. Form Approved OMB No* 0938-0025
  2. Department of Health and Human Services Centers for Medicare Medicaid Services
  3. Completion of this form documents voluntary request for Medicare coverage termination

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About Cms 1763form

CMS-1763 form is a document used by the Centers for Medicare and Medicaid Services (CMS) in the United States. This form is specifically designed for individuals who are applying for Medicare Part B special enrollment period (SEP) due to delayed employer coverage termination. The CMS-1763 form is required for individuals who are currently covered under a group health plan by their employer or spouse's employer and wish to delay their enrollment in Medicare Part B without facing late enrollment penalties. In order to be eligible for the special enrollment period, the individual must meet certain criteria, such as having the employer coverage terminated within the last eight months. By submitting the CMS-1763 form, individuals can provide necessary information to the CMS, proving that they are entitled to a special enrollment period for Medicare Part B. This form helps to ensure that individuals who meet the required criteria can delay their enrollment and avoid penalties for late enrollment. It is important for individuals who are in this specific situation to be aware of the CMS-1763 form and submit it within the specified timeframe to avoid any potential penalties or gaps in their healthcare coverage.

How to complete a CMS 1763 1997 Form

  1. Enter your name, address, mailing address, phone number, and Medicare claim number
  2. Provide the reason for requesting termination of your enrollment under title XVIII of the Social Security Act
  3. Review the information provided and sign the form
  4. If required, have two witnesses sign the form as well
  5. Submit the completed form to the Department of Health and Human Services

People also ask about CMS 1763 1997 Form

What is the purpose of Form CMS-1763 05/97?
Form CMS-1763 05/97 is a request for termination of premium hospital and/or supplementary medical insurance.
Who needs to fill out Form CMS-1763 05/97?
Individuals who wish to terminate their Medicare coverage voluntarily.
Is it mandatory to provide reasons for termination on the form?
While not required, providing reasons helps document the understanding of the effects of the request.

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