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)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.