View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 406.28 42 CFR 407.27 42 CFR 403.13

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

Health Health Care Services

 

197,518 0
   
Individuals or Households
 
   0 %

  Approved 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 197,518 0 83,226 0 114,292 0
Annual IC Time Burden (Hours) 33,578 0 14,491 0 19,087 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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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