SIGNATURE Write in Ink 1. NAME OF WITNESS SIGN HERE ADDRESS MAILING ADDRESS Number and Street City State and Zip Code CITY STATE ZIP CODE DATE Month Day and Year Form CMS-1763 08/06 TELEPHONE NUMBER. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No* 0938-0025 REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE DO NOT WRITE IN THIS SPACE The completion of this form is needed to document your voluntary request for...
cms 1763

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Who needs a Form CMS-1763?

A person who wants to terminate their Medicare coverage (Part B section) should file CMS-1763 to confirm their voluntary decision.

What is Form CMS-1763 for?

While an applicant is not required to give their reasons for requesting termination, the information given by this form will be used as an attestation of understanding the consequences of such refusal. If an applicant is required to pay for their hospital insurance, the termination of their supplementary medical insurance coverage will also end their hospital insurance coverage. Also, an applicant might have to pay a late penalty if they want to re-enroll in the program in the future.

Is Form CMS-1763 accompanied by other forms?

This form does not require the support of other documents and can be filed as it is.

When is Form CMS-1763 due?

You can submit this form at any time, whenever it becomes necessary.

How do I fill out Form CMS-1763?

You must complete this form during an interview with a Social Security representative; you can do this either during a personal interview at a Social Security office or on the phone. Either way, you will have to enlist the testimony of two witnesses who must assure the finished form before submission.

Where do I send Form CMS-1763?

Signed and completed form must be sent to the nearest Social Security office.

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Oh what's going on guys it's Matt from RC overload welcome back um so it's been an interesting winter security for build is a kit itself is built um but we still need to put the electronics in it we still need to paint up the body and I got some scale accessories and detailed stuff that we're going to put on it as well that's coming up here in the next month or two ah still working on everything plus I got a ton of other builds going on as you guys know uh the pro two builds coming up shortly probably by the end of this week hopefully got uh got some more work done to that um and then in the meantime we're still working on the Baja build which guys that is taking a turn for the worst actually right now um we've run into quite a few complications which I will explain a little more when I come up to that video I'm just waiting for some more confirmation emails and figure out some other stuff that's going on with it time is not on our side right now so try and do the best I can on the Baja build we've run into problems but like I said I'll get to that shortly uh and for all of you guys that have been asking over and over and over again about the ECX torment build series I am getting to that I promise uh looking at February is when I will start that build series up again got some ideas for it I'm working on getting the parts for it right now so I'm aiming for February to get that thing started for you guys because I know a lot of you guys are asking for what are the best upgrades what are some cool things to do to it and so forth and I promise you we will get there but in the meantime I got a few other videos that I got to get out before we get into the pro two and the Baja in the ECX torment one of those videos is what I'm covering today as you guys know I have my scx10 here that I've been working on for almost a year now actually um last year in March was the last time this thing was out running and honestly I miss it trying to do the best I can again and out except I want it done my way I want to use all the parts that I want so if I have to wait to get a certain part then I will wait and that's pretty much what's been happening that and it's been kind of pushed off into the backburner a little bit but every so often like today we get a new upgrade in or a new part in and I want to make a video for you guys so what is today's video well it's nothing special because the truck still looks the same or the Jeep but I've installed a panhard bar kit and this is actually a new one that just came out it's made by St RC racing um it's actually a different design than most manufacturers of me so I wanted to talk about it a little bit and I wanted to show you guys how I have it set up in my Jeep the only problem is my Jeep is not a factory setup I have a hundred millimeter shocks in there the king shocks in there and I have the SSD racing axles in this so the setup is not quite the same as what SCRC setup is however I'm going to try to do my very best at...