Form CMS-1763 at a glance
| Official title | Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID) |
| Issued by | Centers for Medicare & Medicaid Services (CMS) |
| Edition | 01/26 |
| Pages | 2 |
| Fillable fields | 27: 23 text fields, 4 checkboxes |
| OMB number | 0938-0025 |
| Official PDF | cms1763.pdf on cms.gov |
| Cost with FillWise | 1 fill |
Counted on Oct 19, 2026 from the official PDF, with the same engine FillWise fills it with.
Form CMS-1763 example, filled out
What Form CMS-1763 asks for
- Page 1: Middle name, Medicare Number, Mailing address, City, State, ZIP code, Phone number, Email address, Name of person completing this form (if not the enrollee), Part A (Hospital and more.
The captions printed next to the first fields of each page, as the PDF gives them.
Fields to watch on Form CMS-1763
- 16 boxes with a fixed number of characters, such as Medicare Number (4), Middle name (4), State (2), ZIP code (5). Long numbers are split across them, so check the digits.
How to fill Form CMS-1763 with FillWise
- Open the official PDF from cms.gov in Chrome.
- In the FillWise side panel, paste your notes or attach a photo of a document, and press Fill form.
- Check all 2 pages of the downloaded PDF before anyone signs.
Without the extension: Fill a PDF in your account.
How FillWise handles Form CMS-1763
FillWise fills this form the regular way: the AI reads each field's printed caption, its tooltip and its options, and answers from your notes.
The form has 2 digital signature fields. FillWise leaves them empty: signing is yours.
What to check before you file
- The edition. Agencies replace their forms with new editions. This page describes the 01/26 edition; check that your copy is still the current one on cms.gov.
- Tick only the coverage you mean to end: the form notes that ending Part B also ends Part A when you pay a premium for Part A.
- Names and numbers character by character; signatures, fees and supporting documents stay with you.
Filling Form CMS-1763 for many people
Bulk fill in your FillWise account takes Form CMS-1763 and a CSV or Excel sheet with one person per row. It fills the first one and stops so you can check the result, then fills the rest and hands back one zip. Each copy costs 1 fill, the same as filling it on its own. How it works step by step: bulk PDF form filling guide.
Cost
Form CMS-1763 has 2 pages, but its fields are on page 1 only, so filling it costs 1 fill: FillWise charges a PDF fill by the pages it fills, one fill per started 5 pages. The free plan starts with 20 fills and then tops back up to 5 fills a week, no card required. Paid plans are on the pricing page.
Privacy
The PDF is filled in your browser; only its field list and your data go to our server for the AI, and nothing is stored. Details: privacy and security.