View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance	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 403.13 42 CFR 407.27 42 CFR 406.28

Information Collection Instruments:

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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 114,292	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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

Documents for IC

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.