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Federal forms, ICRs, and supporting documents

Information Collection

"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)

IC 179179 under ICR 200902-0938-003 · OMB 0938-0910.

Documents and Forms
Document Name
Document Type
Other-Instruction CMS-10095 updated
Other-Instruction : Original
Other-Spanish Version
Information Collection (IC) Details

View Information Collection (IC)

"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)
 
No Modified
 
Mandatory
 
42 CFR 422.624(b)(1) 42 CFR 422.626(e)(1)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Instruction CMS-10095 updated CMS-10095 Form Instructions DENC2007fix.doc Yes Yes Paper Only
Other-Instruction : Original DENCInstructions.pdf Yes Yes Paper Only
Other-Spanish Version CMS-10095-DENC_Spa2008 (4) (3)final.doc No No Paper Only

Health Health Care Services

 

454 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 38,046 0 0 0 0 38,046
Annual IC Time Burden (Hours) 9,512 0 0 0 0 9,512
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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