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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	Form and Instruction
Form CMS-1763 Request for Termination of Premium Part A, Part B or Part B Immunosuppressive Drug Coverage Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	Form and Instruction
Form CMS-1763A Request to Cancel Medicare Part B (Medical Insurance) Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	Form and Instruction
CMS-1763 Request for Termination of Premium Part A, Part B or Par CMS-1763 .pdf	Form and Instruction
CMS-1763 Request for Termination of Premium Part A, Part B or Par CMS-1763 .pdf	Form and Instruction
CMS-1763A Request to Cancel Medicare Part B (Medical Insurance) CMS-1763A.pdf	Form and Instruction
CMS-1763A Request to Cancel Medicare Part B (Medical Insurance) CMS-1763A.pdf	Form and Instruction
CMS-1763-508 DEEP Redline.pdf Track Change: Request for Termination form	IC Document
CMS-1763-508 DEEP Redline.pdf Track Change: Request for Termination form	IC Document

IC Title:

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 406.28 42 CFR 407.27 42 CFR 403.13

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				Yes	No	Fillable Fileable
Form and Instruction	CMS-1763A				Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 197,518

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	197,518	83,226	114,292
Annual IC Time Burden (Hours)	33,578	14,491	19,087
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 form		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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