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⚠️ Notice: This information collection may be outdated.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 Name | Status |
|---|---|
Form and Instruction |
Modified |
Supporting Statement A | 2022-11-04 |
Form CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage
CMS-1763 - Supporting Statement A (CMS-4199-F version 6).docxIC Document Collections
| IC ID | Document Title | Status | |
|---|---|---|---|
| 43649 | Modified |
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug CoverageICR 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 |