Information Collection Request
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763)
ICR 202210-0938-007 · OMB 0938-0025 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0025 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage |
Form and Instruction | Modified | Repair queued |
 CMS-1763 - Supporting Statement A (CMS-4199-F version 6).docx |
Supporting Statement A | Uploaded 2022-11-04 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 43649 |  Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0025 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202207-0938-002 |
| Agency Tracking No | CM-CPC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |