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Federal forms, ICRs, and supporting documents

Information Collection

Notification of Involuntary Disenrollment by the Centers for Medicare & Medicaid Services for Failure to Pay the Part D Income Related Monthly Adjustment Amount (CMS-10352

IC 195404 under ICR 201011-0938-012 · OMB 0938-1335.

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

View Information Collection (IC)

Notification of Involuntary Disenrollment by the Centers for Medicare & Medicaid Services for Failure to Pay the Part D Income Related Monthly Adjustment Amount (CMS-10352
 
No New
 
Mandatory
 
42 CFR 423.44(e)(4)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction PRA D-IRMAA Instructions for Completing Notice CMS 10352.pdf No No Printable Only
Form CMS-10352 Notification of Involuntary Disenrollment PRA D-IRMAA Disnerollment Notice CMS 10352.pdf No No Printable Only

Health Health Care Services

 

80,000 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Requested 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 80,000 80,000 0 0 0 0
Annual IC Time Burden (Hours) 8,000 8,000 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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