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Federal forms, ICRs, and supporting documents

Information Collection

Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR Sections 406.13 and 407.27

IC 43649 under ICR 200908-0938-010 · OMB 0938-0025.

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Form
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Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR Sections 406.13 and 407.27
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 403.13 42 CFR 407.27

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-1763 REQUEST FOR TERMINATION OF PREMIUM HOSPITALAND/OR SUPPLEMENTARY MEDICAL INSURANCE CMS-1763-508.pdf Yes Yes Paper Only

Health Health Care Services

 

14,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 14,000 0 0 0 0 14,000
Annual IC Time Burden (Hours) 5,831 0 0 -2 0 5,833
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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