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

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

Documents and Forms

Document Name Document Type
PRA D-IRMAA Instructions for Completing Notice CMS 10352.pdf Instruction
CMS-10352 Notification of Involuntary Disenrollment PRA D-IRMAA Disnerollment Notice CMS 10352.pdf Form

Information Collection (IC) Details

IC Title:	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	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.44(e)(4)

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	80,000	80,000
Annual IC Time Burden (Hours)	8,000	8,000
Annual IC Cost Burden (Dollars)	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.