Information Collection

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

IC 43649 under ICR 202207-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-1763 Request for Termination of Premium Part A, Part B or Par CMS-1763-508C_508.pdf	Form and Instruction
CMS-1763 Request for Termination of Premium Part A, Part B or Par CMS-1763-508C_508.pdf	Form and Instruction
CMS-1763 Track Changes.pdf Track Change: Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	IC Document
Crosswalk of Changes CMS 1763.docx Crosswalk: Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	IC Document

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 42 CFR 406.28

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 Part A, Part B or Part B Immunosuppressive Drug Coverage	CMS-1763-508C_508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 114,292

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	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	114,292	77	114,215
Annual IC Time Burden (Hours)	19,087	13	19,074
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change: Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	CMS-1763 Track Changes.pdf	09/08/2022
Crosswalk: Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	Crosswalk of Changes CMS 1763.docx	09/08/2022

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