Information Collection

Medicare+Choice Disenrollment Form to Original Medicare and Supporting Regulations 422.66

IC 8427 under ICR 200210-0938-007 · OMB 0938-0741.

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Information Collection (IC) Details

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IC Title:	Medicare+Choice Disenrollment Form to Original Medicare and Supporting Regulations 422.66	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	50,000	-10,000	60,000
Annual IC Time Burden (Hours)	3,300	-660	3,960
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.