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Federal forms, ICRs, and supporting documents

Information Collection

Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage

IC 43649 under ICR 202508-0938-004 · OMB 0938-0025.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 406.28 42 CFR 407.27 42 CFR 403.13

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 .pdf Yes No Fillable Fileable
Form and Instruction CMS-1763A Request to Cancel Medicare Part B (Medical Insurance) CMS-1763A.pdf Yes No Fillable Fileable

Health Health Care Services

 

197,518 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 197,518 0 83,226 0 114,292 0
Annual IC Time Burden (Hours) 33,578 0 14,491 0 19,087 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Change: Request for Termination form CMS-1763-508 DEEP Redline.pdf 08/05/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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