Information Collection

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

IC 43649 under ICR 202104-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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	Form and Instruction
CMS-1763 Request for Termination of Premium Hospital and/or Suppl CMS-1763.pdf secure.ssa.gov/apps10/poms/images/Other/G-CMS-1763.pdf	Form and Instruction

IC Title:

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

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 114,215

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	114,215	13,215	101,000
Annual IC Time Burden (Hours)	19,074	2,241	16,833
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.