If you wish to disenroll from Medicare Part B, you will need to submit form CMS-1763 to Social Security.  The form is used to voluntarily terminate entitlement to Supplementary Medical Insurance (Part B) and Premium hospital Insurance and is owned by the Center for Medicare and Medicaid Services  (CMS). 

CMS requires that a personal interview be conducted with every individual who wishes to terminate entitlement and so Social Security does not offer form CMS-1763 on the public Internet site.  The form will be completed during an in-person or phone interview so that Social Security can ensure that the beneficiary understands the ramifications of termination. 

After the interview, Social Security’s representative is required to provide you with a letter outlining the consequences of voluntary termination and of the right to withdraw the termination request before coverage ends.  Disenrolling is a serious decision; if you wish to reenroll later, you may have to pay a surcharge. 

Termination of Medicare Part B will be effective at the end of the month following the month in which the termination request is filed.

For an interview, call the Social Security Administration’s toll-free number, 1-800-772-1213 or contact your local Social Security office.