Request for Termination of Premium Hospital and/or Supplementary Medical Insurance and Supporting Regulations on 42 CFR 406.28 and 407.27

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Information Collection (IC) Details

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IC Title:	Request for Termination of Premium Hospital and/or Supplementary Medical Insurance and Supporting Regulations on 42 CFR 406.28 and 407.27	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-1763				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	14,000	14,000
Annual IC Time Burden (Hours)	5,833	5,833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.