Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers

Data collection for Medicare Beneficiaries Receiving FDG Positron Emission Tomography (PET) for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and All Other Cancers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0968 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10152 Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers Form and Instruction
CMS-10152 NOPR case_registration NOPR case_registration.pdf Form and Instruction
CMS-10152 NOPR pre_PET_form NOPR pre_PET_form.pdf Form
CMS-10152 NOPR referring_md_sheet NOPR referring_md_sheet.pdf Form
CMS-10152 NOPR_PET_complete_form NOPR_PET_complete_form.pdf Form
CMS-10152 NOPR_PET_report_submission_form NOPR_PET_report_submission_form.pdf Form
CMS-10152 NOPR_post_PET__form NOPR_post_PET__form.pdf Form

Information Collection (IC) Details

IC Title:	Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10152	NOPR case_registration	NOPR case_registration.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10152	NOPR pre_PET_form	NOPR pre_PET_form.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10152	NOPR referring_md_sheet	NOPR referring_md_sheet.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10152	NOPR_PET_complete_form	NOPR_PET_complete_form.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10152	NOPR_PET_report_submission_form	NOPR_PET_report_submission_form.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10152	NOPR_post_PET__form	NOPR_post_PET__form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Data Collection Secondary to Coverage Decision System	FR Citation: 70 FR 53667

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	4,167	4,167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.