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

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

Documents and Forms
Document Name
Document Type
Instruction
Form
Form
IC Document
IC Document
Information Collection (IC) Details

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Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)
 
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
Instruction NOMNC Form Instructions - 2010 - 508.doc Yes No Printable Only
Form CMS-10095-NOMNC Notice of Medicare Non-Coverage NOMNC508 - 2010.doc Yes No Fillable Printable
Form CMS-10095-NOMNC-SP Notificaci?n de Medicare de Terminaci?n de Cobertura CMS10095-NOMNC508-2010 spa.doc Yes No Fillable Printable

Health Health Care Services

 

24,915 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 80,628 0 0 0 0 80,628
Annual IC Time Burden (Hours) 20,157 0 0 0 0 20,157
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
NOMNCforminstructionstrackchanges508 NOMNCforminstructionstrackchanges508.docx 07/30/2010
NOMNCtrackchanges508 NOMNCtrackchanges508.docx 07/30/2010
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.