Medicare+Choice Disenrollment Form to Original Medicare

Medicare+Choice Disenrollment Form to Original Medicare

OMB: 0938-0741

IC ID: 8425

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Medicare+Choice Disenrollment Form to Original Medicare
 
No Migrated
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HCFA-R-257 No No


    

60,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 60,000 0 60,000 0 0 0
Annual IC Time Burden (Hours) 3,960 0 3,960 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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