Information Collection

Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193)

IC 8309 under ICR 201005-0938-005 · OMB 0938-0692.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0692 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-193 Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193)	Form and Instruction
CMS-R-193 An Important Message From Medicare About Your Rights im508final.doc	Form and Instruction
CMS-R-193-SP Mensaje Importante De Medicare Sobre Sus Derechos IM Spanish final.docx	Form and Instruction

IC Title:

Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.1205 42 CFR 422.620

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-193	An Important Message From Medicare About Your Rights	im508final.doc		No	No	Paper Only
Form and Instruction	CMS-R-193-SP	Mensaje Importante De Medicare Sobre Sus Derechos	IM Spanish final.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,163

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,680,000	6,680,000	13,000,000
Annual IC Time Burden (Hours)	2,952,000	-298,000	3,250,000
Annual IC Cost Burden (Dollars)	0	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.