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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1763 Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance	Form and Instruction	Modified	Repair queued
CMS-1763.Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2022-07-05	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43649	Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0025	ICR Reference No: 202207-0938-002
Status: Received in OIRA	Previous ICR Reference No: 202104-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR 406.13 and 407.27 (CMS-1763)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/05/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2025
Responses	114,292	114,215
Time Burden (Hours)	19,087	19,074
Cost Burden (Dollars)	0	0

---

Abstract: The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital (premium-HI) and/or Supplementary Medical Insurance (SMI).

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1838
   PL: Pub.L. 116 - 120 402 Name of Law: Consolidated Appropriations Act of 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 116 - 120 402 Name of Law: Consolidated Appropriations Act of 2021

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU85	Proposed rulemaking	87 FR 25090	04/27/2022

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance	CMS-1763, CMS-1763	Request for Termination of Premium Hospital and/or Supplementary Medical Insurance ,   Request for Termination of Premium Part A, Part B or Part B Immunosuppressive Drug Coverage

---

ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	114,292	114,215	77	0	0	0
Annual Time Burden (Hours)	19,087	19,074	13	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of respondents has increased and the burden has been adjusted accordingly.

---

Annual Cost to Federal Government: $755,253

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/05/2022

---