Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage

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)

Documents and Forms

Document Name Document Type
Form CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage Form and Instruction
CMS-1763 Request for Termination of Premium Part A, Part B or Par CMS-1763 .pdf Form and Instruction
CMS-1763A Request to Cancel Medicare Part B (Medical Insurance) CMS-1763A.pdf Form and Instruction
CMS-1763-508 DEEP Redline.pdf Track Change: Request for Termination form IC Document

Information Collection (IC) Details

IC Title:	Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	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 406.28 42 CFR 407.27

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 .pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-1763A	Request to Cancel Medicare Part B (Medical Insurance)	CMS-1763A.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 197,518	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

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

Documents for IC

Title	Document	Date Uploaded
Track Change: Request for Termination form	CMS-1763-508 DEEP Redline.pdf	08/05/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.