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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10352 Notification of Involuntary Disenrollment 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	Form
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

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					No	No	Printable Only
Form	CMS-10352				No	No	Printable Only

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

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.

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