OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance

IC 43649 under ICR 202207-0938-002 · OMB 0938-0025.

Documents and Forms
Document Name
Document Type
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-Hospital and/or Supplementary Medical Insurance
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 403.13 42 CFR 407.27 42 CFR 406.28

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

Health Health Care Services

 

114,292 0
   
Individuals or Households
 
   0 %

  Requested 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 114,292 77 0 0 0 114,215
Annual IC Time Burden (Hours) 19,087 13 0 0 0 19,074
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.