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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