Information Collection

CMS-R-10 Form 83 - Part II (Developing Advanced Directive)

IC 189098 under ICR 200810-0938-019 · OMB 0938-0610.

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Information Collection (IC) Details

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IC Title:	CMS-R-10 Form 83 - Part II (Developing Advanced Directive)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.128 42 CFR 489.102(a)(2) 42 CFR 417.436(d)(iii)

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36,784	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, 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	36,784	36,784
Annual IC Time Burden (Hours)	36,784	36,784
Annual IC Cost Burden (Dollars)	0	0

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