Information Collection

Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)

IC 179179 under ICR 201011-0938-009 · OMB 0938-0910.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0910 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10095-NOMNC Notice of Medicare Non-Coverage Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)	Form
Form CMS-10095-NOMNC-SP Notificaci?n de Medicare de Terminaci?n de Cobertura Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)	Form
NOMNC Form Instructions - 2010 - 508.doc	Instruction
CMS-10095-NOMNC Notice of Medicare Non-Coverage NOMNC508 - 2010.doc	Form
CMS-10095-NOMNC-SP Notificaci?n de Medicare de Terminaci?n de Cobertura CMS10095-NOMNC508-2010 spa.doc	Form
NOMNCforminstructionstrackchanges508.docx NOMNCforminstructionstrackchanges508	IC Document
NOMNCtrackchanges508.docx NOMNCtrackchanges508	IC Document

IC Title:

Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.624(b)(1) 42 CFR 422.626(e)(1)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Form	CMS-10095-NOMNC	Yes	No	Fillable Printable
Form	CMS-10095-NOMNC-SP	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,915

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	Previously Approved
Annual Number of Responses for this IC	80,628	80,628
Annual IC Time Burden (Hours)	20,157	20,157
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NOMNCforminstructionstrackchanges508		07/30/2010
NOMNCtrackchanges508		07/30/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].