Survey of Newly Eligible Medicare Beneficiaries

Documents and Forms

Document Name Document Type
Form CMS-10050 Survey of Newly Eligible Medicare Beneficiaries Form and Instruction
CMS-10050 Survey of Newly Eligible Medicare Beneficiaries CMS-10050.Collection Instrument.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey of Newly Eligible Medicare Beneficiaries	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10050	Survey of Newly Eligible Medicare Beneficiaries	CMS-10050.Collection Instrument.doc		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,200	-1,200	2,400
Annual IC Time Burden (Hours)	300	-500	800
Annual IC Cost Burden (Dollars)	0	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.