Application for Health Insurance Benefits Under Medicare for Individual with Chronic Renal Disease and Supporting Regulations in 42 CFR 406.7 and .13

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Information Collection (IC) Details

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IC Title:	Application for Health Insurance Benefits Under Medicare for Individual with Chronic Renal Disease and Supporting Regulations in 42 CFR 406.7 and .13	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-43				Yes	Yes

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: 90 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60,000	-30,000	90,000
Annual IC Time Burden (Hours)	26,000	0	26,000
Annual IC Cost Burden (Dollars)	0	0	0

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