+-------------------------------+---+------+------+-----------------+
| **REQUEST FOR TERMINANTION OF |   |      | #    |                 |
| PREMIUM HOSPITAL AND/OR       |   |      | ###  |                 |
| SUPPLEMENTARY MEDICAL         |   |      |      |                 |
| INSURANCE**                   |   |      | ###  |                 |
|                               |   |      | # DO |                 |
| The completion of this form   |   |      |  NOT |                 |
| is needed to document your    |   |      |  WRI |                 |
| voluntary request for         |   |      | TE I |                 |
| termination of Medicare       |   |      | N TH |                 |
| coverage as permitted under   |   |      | IS S |                 |
| the Code of Federal           |   |      | PACE |                 |
| Regulations.                  |   |      |      |                 |
|                               |   |      |      |                 |
| Sections 1838(b) and          |   |      |      |                 |
| 1818(c)(4) of the Social      |   |      |      |                 |
| Security Act require filing   |   |      |      |                 |
| of notice advising the        |   |      |      |                 |
| Administration when           |   |      |      |                 |
| termination of Medicare       |   |      |      |                 |
| coverage is requested. While  |   |      |      |                 |
| you are not required to give  |   |      |      |                 |
| your reasons for requesting   |   |      |      |                 |
| termination, the information  |   |      |      |                 |
| given will be used to         |   |      |      |                 |
| document your understanding   |   |      |      |                 |
| of the effects of your        |   |      |      |                 |
| request.                      |   |      |      |                 |
+-------------------------------+---+------+------+-----------------+
| ##### NAME OF ENROLEE         |   |      | #### |                 |
|                               |   |      | ## M |                 |
|                               |   |      | EDIC |                 |
|                               |   |      | ARE  |                 |
|                               |   |      | CLAI |                 |
|                               |   |      | M NU |                 |
|                               |   |      | MBER |                 |
|                               |   |      |      |                 |
|                               |   |      | #    |                 |
|                               |   |      | ##   |                 |
+-------------------------------+---+------+------+-----------------+
| # NAME OF PER                 | # |      |      | # DA            |
| SON, IF OTHER THAN ENROLLEE,  |   |      |      | TE SUPPEMENTARY |
| WHO IS EXECUTING THIS REQUEST | T |      |      |                 |
|                               | H |      |      | # INS           |
|                               | I |      |      | URANCE WILL END |
|                               | S |      |      |                 |
|                               |   |      |      | **November 13,  |
|                               | I |      |      | 2023**          |
|                               | S |      |      |                 |
|                               |   |      |      |                 |
|                               | A |      |      |                 |
|                               |   |      |      |                 |
|                               | R |      |      |                 |
|                               | E |      |      |                 |
|                               | Q |      |      |                 |
|                               | U |      |      |                 |
|                               | E |      |      |                 |
|                               | S |      |      |                 |
|                               | T |      |      |                 |
|                               |   |      |      |                 |
|                               | F |      |      |                 |
|                               | O |      |      |                 |
|                               | R |      |      |                 |
|                               |   |      |      |                 |
|                               | T |      |      |                 |
|                               | E |      |      |                 |
|                               | R |      |      |                 |
|                               | M |      |      |                 |
|                               | I |      |      |                 |
|                               | N |      |      |                 |
|                               | A |      |      |                 |
|                               | T |      |      |                 |
|                               | I |      |      |                 |
|                               | O |      |      |                 |
|                               | N |      |      |                 |
|                               |   |      |      |                 |
|                               | O |      |      |                 |
|                               | F |      |      |                 |
|                               | : |      |      |                 |
|                               |   |      |      |                 |
|                               | # |      |      |                 |
|                               |   |      |      |                 |
|                               |   |      |      |                 |
+-------------------------------+---+------+------+-----------------+
| #                             |   |      |      |                 |
|                               |   |      |      |                 |
| #  I reque                    |   |      |      |                 |
| st termination of my enrollme |   |      |      |                 |
| nt under the above provisions |   |      |      |                 |
|  of title XVIII of the Social |   |      |      |                 |
|  Security Act, as amended, fo |   |      |      |                 |
| r the reason(s) stated below: |   |      |      |                 |
|                               |   |      |      |                 |
| #                             |   |      |      |                 |
+-------------------------------+---+------+------+-----------------+
| #                             |   |      |      |                 |
|                               |   |      |      |                 |
| I reside in Venezuela and     |   |      |      |                 |
| Medicare coverage does not    |   |      |      |                 |
| apply to me while abroad.     |   |      |      |                 |
| Please STOP all Medicare Part |   |      |      |                 |
| B deductions at once.         |   |      |      |                 |
|                               |   |      |      |                 |
| I UNDERSTAND THAT IF I AM     |   |      |      |                 |
| REQUIRED TO PAY FOR MY        |   |      |      |                 |
| HOSPITAL INSURANCE, THE       |   |      |      |                 |
| TERMINATION OF MY             |   |      |      |                 |
| SUPPLEMENTARY MEDICAL         |   |      |      |                 |
| INSURANCE COVERAGE WILL ALSO  |   |      |      |                 |
| END MY HOSPITAL INSURANCE     |   |      |      |                 |
| COVERAGE.                     |   |      |      |                 |
+-------------------------------+---+------+------+-----------------+
| SIGNATURE                     |   | DATE |      |                 |
|                               |   | (Mo  |      |                 |
|                               |   | nth, |      |                 |
|                               |   | day, |      |                 |
|                               |   | y    |      |                 |
|                               |   | ear) |      |                 |
|                               |   |      |      |                 |
|                               |   | Mon  |      |                 |
|                               |   | day, |      |                 |
|                               |   | Nove |      |                 |
|                               |   | mber |      |                 |
|                               |   | 13,  |      |                 |
|                               |   | 2023 |      |                 |
+-------------------------------+---+------+------+-----------------+
| MAILING ADDRESS:              |   | T    |      |                 |
|                               |   | elep |      |                 |
|                               |   | hone |      |                 |
|                               |   | nu   |      |                 |
|                               |   | mber |      |                 |
|                               |   | (Inc |      |                 |
|                               |   | lude |      |                 |
|                               |   | Area |      |                 |
|                               |   | C    |      |                 |
|                               |   | ode) |      |                 |
+-------------------------------+---+------+------+-----------------+

**FORM HCFA 1763** USGPO 1984-421-101/14393