Information Collection

Medicare Advantage & Part D Disenrollment Requests Through 1-800-MEDICARE (CMS-R-257)

IC 8428 under ICR 200811-0938-001 · OMB 0938-0741.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attmt B_gen-disenrollment_script_7-10-08.doc	Other-Script

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Script			Attmt B_gen-disenrollment_script_7-10-08.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 117,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	117,000	67,000	50,000
Annual IC Time Burden (Hours)	19,539	16,239	3,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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