Information Collection

Advance Beneficiary Notice and Supporting Regulations in 42 CFR 411.404, 411.406, and 411.408

IC 8161 under ICR 200204-0938-006 · OMB 0938-0566.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0566 can be found here:

Documents and Forms

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IC Title:

Advance Beneficiary Notice and Supporting Regulations in 42 CFR 411.404, 411.406, and 411.408

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,028,585

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,660,110	836,960	18,823,150
Annual IC Time Burden (Hours)	1,638,345	69,749	1,568,596
Annual IC Cost Burden (Dollars)	122,700,000	122,700,000	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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

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