REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE "MEDICARE"

ICR 198901-0938-003

OMB: 0938-0025

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0025 198901-0938-003
Historical Active 198505-0938-004
HHS/CMS
REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE "MEDICARE"
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 03/09/1989
Retrieve Notice of Action (NOA) 01/11/1989
  Inventory as of this Action Requested Previously Approved
03/31/1992 03/31/1992
30,000 0 0
5,000 0 0
0 0 0

THE HCFA-1763 IS THE FORM AN-INDIVIDUAL COMPLETES WHEN HE/SHE WISHES TO TERMINATE MEDICARE COVERAGE. THIS FORM IS THE VEHICLE BY WHICH THE SSA PROGRAM SERVICES CENTER IS MADE AWARE OF THE BENEFICIARY'S DESIRE TO WITHDRAW FROM MEDICARE.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE "MEDICARE" HCFA-1763

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 30,000 0 0 30,000 0 0
Annual Time Burden (Hours) 5,000 0 0 5,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
01/11/1989


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