Information Collection

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

IC 8163 under ICR 201102-0938-010 · OMB 0938-0566.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0566 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
508ABNinstructions.pdf	Instruction
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) 508ABNwatermarked.pdf	Form
CMS-R-131 Notificaci?n previa de NO-cobertura al beneficiario (ABN 508spanishabnwatermarked.pdf	Form
2011ABNFormInstructions508trackchanges.doc 2011ABNFormInstructions508trackchanges	IC Document
2011ABN508trackchanges.docx 2011ABN508trackchanges	IC Document
2011spanishabn508trackchanges.doc 2011spanishabn508trackchanges	IC Document

IC Title:

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			508ABNinstructions.pdf	Yes	Yes	Paper Only
Form	Form CMS-R-131	Advance Beneficiary Notice of Noncoverage (ABN)	508ABNwatermarked.pdf	Yes	No	Paper Only
Form	CMS-R-131	Notificaci?n previa de NO-cobertura al beneficiario (ABN)	508spanishabnwatermarked.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,326,282

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	43,725,850	3,423,344	40,302,506
Annual IC Time Burden (Hours)	5,099,309	397,350	4,701,959
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2011ABNFormInstructions508trackchanges	2011ABNFormInstructions508trackchanges.doc	01/05/2011
2011ABN508trackchanges	2011ABN508trackchanges.docx	01/05/2011
2011spanishabn508trackchanges	2011spanishabn508trackchanges.doc	01/05/2011

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