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

Advanced Directives (Medicare and Medicard) - BDP-718

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0610 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	CMS-R-10 Form 83 - Part II (Documenting 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	20,267,984	20,267,984
Annual IC Time Burden (Hours)	1,013,399	1,013,399
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.