Information Collection

"Detailed Explanation of Non-Coverage" and "Important Medicare Message of Non-Coverage" and Supporting Regulations in 42 CFR 422.620, 422.624, and 422.626

IC 8750 under ICR 200311-0938-008 · OMB 0938-0910.

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Information Collection (IC) Details

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IC Title:	"Detailed Explanation of Non-Coverage" and "Important Medicare Message of Non-Coverage" and Supporting Regulations in 42 CFR 422.620, 422.624, and 422.626	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	CMS-10095				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22,247	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	612,000	612,000
Annual IC Time Burden (Hours)	68,000	68,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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