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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0025 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1763 Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR Sections 406.13 and 407.27 Form
CMS-1763 Request for Termination of Premium Hospital and/or Suppl CMS-1763-508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR Sections 406.13 and 407.27	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 403.13 42 CFR 407.27

Information Collection Instruments:

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 Hospital and/or Supplementary Medical Insurance	CMS-1763-508.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

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

Documents for IC

Title	Document	Date Uploaded
No associated records found

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