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OMB Control No: 0938-0025	ICR Reference No: 202508-0938-004
Status: Received in OIRA	Previous ICR Reference No: 202210-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID) and Request to Cancel Medicare Part B (Medical Insurance) (CMS-1763)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/05/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	197,518	0
Time Burden (Hours)	33,578	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	197,518	83,226	114,292
Annual Time Burden (Hours)	33,578	14,491	19,087
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The hourly burden from the 2022 approved submission increased from 19,087 hours to 33,578,380 hours -- a change of 14,491. The change is due to a marginal increase in terminations from the 2022 submission to the 2024

Annual Cost to Federal Government: $1,469,549

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov