Information Collection

Hme Health Advance Beneficiary Notices (HHABNs) and Supporting Regulations in 42 CFR, Sections 411.404-.406, and 484.10\

IC 8540 under ICR 200004-0938-004 · OMB 0938-0781.

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Information Collection (IC) Details

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IC Title:	Hme Health Advance Beneficiary Notices (HHABNs) and Supporting Regulations in 42 CFR, Sections 411.404-.406, and 484.10\	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-296				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 540,000	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	Previously Approved
Annual Number of Responses for this IC	1,080,000	720,000	360,000
Annual IC Time Burden (Hours)	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0

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Title	Document	Date Uploaded

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