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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.