Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR Sections 406.28 and 407.27

ICR 200606-0938-002

OMB: 0938-0025

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0025 200606-0938-002
Historical Active 200304-0938-003
HHS/CMS
Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR Sections 406.28 and 407.27
Extension without change of a currently approved collection   No
Regular
Approved without change 08/28/2006
Retrieve Notice of Action (NOA) 06/12/2006
  Inventory as of this Action Requested Previously Approved
08/31/2009 36 Months From Approved 08/31/2006
14,000 0 14,000
5,833 0 5,833
0 0 0

The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital (premium-HI) and/or Supplementary Medical Insurance (SMI).

None
None


No

  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 14,000 14,000 0 0 0 0
Annual Time Burden (Hours) 5,833 5,833 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
06/12/2006


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