- Form #
- CMS 1763
- Form Title
- REQ FOR TERMINATION OF PREMIUM HI/SMI
- Revision Date
- 05/01/1997
- O.M.B. #
- 0938-0025
- O.M.B. Expiration Date
- 10/31/2012
- CMS Manual
- N/A
- Special Instructions
- You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213