Information Collection

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

IC 8828 under ICR 200811-0938-006 · OMB 0938-0968.

⚠️ Notice: This information collection may be referencing outdated material.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

View Information Collection (IC)

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.