Individuals enrolled in Medicare Part B or premium Part A who wish to terminate their coverage may submit this form.
Use it when you want to cancel your Medicare Part B (or premium Part A) coverage, typically because you have other health insurance or you no longer wish to pay the premiums.
You must provide your Medicare number, current coverage details, the reason for termination and the signature of a witness.
Your Part B coverage will end, and you may face a late‑enrollment penalty if you decide to re‑enroll later.
Contact the Social Security Administration or your local State Health Insurance Assistance Program (SHIP) for assistance.
The Social Security Administration will process your request, send confirmation of termination and inform you of any further steps.
Yes, you can re‑enroll during the General Enrollment Period or a Special Enrollment Period, but you may be subject to late‑enrollment penalties.
You may lose coverage for immunosuppressive drugs used after a kidney transplant; consult your plan about alternative coverage before terminating Part B.
