OMB
.report
Search
Medicare+Choice Disenrollment Form to Original Medicare
Medicare+Choice Disenrollment Form to Original Medicare
OMB: 0938-0741
IC ID: 8425
OMB.report
HHS/CMS
OMB 0938-0741
ICR 199809-0938-002
IC 8425
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0741 can be found here:
2008-11-04 - Revision of a currently approved collection
2005-10-26 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Medicare+Choice Disenrollment Form to Original Medicare
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
HCFA-R-257
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
60,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.