Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance

Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR 406.13 and 407.27 (CMS-1763)

OMB: 0938-0025

IC ID: 43649

Information Collection (IC) Details

View Information Collection (IC)

Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance
 
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 and Instruction CMS-1763 Request for Termination of Premium Hospital and/or Supplementary Medical Insurance CMS-1763 508.pdf https://secure.ssa.gov/apps10/poms/images/Other/G-CMS-1763.pdf No   Fillable Fileable

Health Health Care Services

 

101,000 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 101,000 0 0 87,000 14,000 0
Annual IC Time Burden (Hours) 16,833 0 0 11,000 5,833 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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