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Federal forms, ICRs, and supporting documents

Information Collection

Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

IC 184965 under ICR 200805-0938-009 · OMB 0938-0953.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form
Form
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
 
No New
 
Required to Obtain or Retain Benefits
 
42 CFR 405.1200 42 CFR 405.1202

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Detailed instructions-clean-2-15.doc Yes Yes Paper Only
Form CMS-10124 Detailed Explanation of Non-coverage Detailed Notice-clean-2-15-08.doc Yes Yes Paper Only
Form CMS-10124 Detailed Explanation of Non-Coverage (Redline) Detailed Notice-Redline-2-4-08.doc Yes Yes Paper Only
Form CMS-10123 Notice of Medicare Provider Non-Coverage Generic Notice-clean-2-15.doc Yes Yes Paper Only
Form CMS-10123 Notice of Medicare Provider Non-Coverage (Redline Generic Notice-Redline-2-4-08.doc Yes Yes Paper Only
Instruction Generic Noticed Form Instructions-clean-2-15 .doc Yes Yes Paper Only

Health Health Care Services

 

15,637 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 15,637 0 0 15,637 0 0
Annual IC Time Burden (Hours) 5,472 0 0 5,472 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CROSSWALK DOC 020508 CROSSWALK DOC 020508 .doc 05/15/2008
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.