Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763)

OMB 0938-0025

The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital (premium-HI) and/or Supplementary Medical Insurance (SMI).

The latest form for Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763) expires 2021-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage Form and Instruction
CMS-1763 - Supporting Statement A (CMS-4199-F version 6).docx Supporting Statement A
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage Form and Instruction

All Historical Document Collections

202210-0938-007 Approved without change	Revision of a currently approved collection	2022-11-04
202207-0938-002 Comment filed on proposed rule and continue	Revision of a currently approved collection	2022-07-05
202104-0938-002 Approved without change	Extension without change of a currently approved collection	2021-04-13
201712-0938-010 Approved without change	Reinstatement without change of a previously approved collection	2018-01-25
201309-0938-023 Approved without change	Reinstatement without change of a previously approved collection	2013-09-19
200908-0938-010 Approved without change	Extension without change of a currently approved collection	2009-08-19
200606-0938-002 Approved without change	Extension without change of a currently approved collection	2006-06-12
200304-0938-003 Approved without change	Extension without change of a currently approved collection	2003-04-11
200009-0938-003 Approved without change	Extension without change of a currently approved collection	2000-09-01
199709-0938-003 Approved without change	Reinstatement without change of a previously approved collection	1997-09-03
199206-0938-002 Approved without change	Reinstatement with change of a previously approved collection	1992-06-22
198901-0938-003 Approved without change	Reinstatement with change of a previously approved collection	1989-01-11
198505-0938-004 Approved without change	Extension without change of a currently approved collection	1985-05-30
198205-0938-003 Approved without change	Extension without change of a currently approved collection	1982-05-12
197707-0938-003 Approved without change	Revision of a currently approved collection	1977-07-05
197707-0938-002 Approved without change	Revision of a currently approved collection	1977-07-01