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 201309-0938-023 · OMB 0938-0025.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.