ESRD Beneficiary Selection and Supporting Regulations Contained in 42 CFR 414.330

Documents and Forms

Document Name Document Type
Form CMS-382 ESRD Beneficiary Selection and Supporting Regulations Contained in 42 CFR 414.330 Form and Instruction
CMS-382 ESRD Beneficiary Selection CMS382.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ESRD Beneficiary Selection and Supporting Regulations Contained in 42 CFR 414.330	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 414.330

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-382	ESRD Beneficiary Selection	CMS382.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,400	7,400
Annual IC Time Burden (Hours)	617	617
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.