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Form CMS-1763 Request for Termination of Premium Part A, Part B or Par
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763)
CMS-1763-508C_508
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage
OMB: 0938-0025
OMB.report
HHS/CMS
OMB 0938-0025
ICR 202210-0938-007
IC 43649
Form CMS-1763 Request for Termination of Premium Part A, Part B or Par
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0025 can be found here:
2025-08-05 - Reinstatement with change of a previously approved collection
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