Information Collection

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

IC 179179 under ICR 201106-0938-017 · OMB 0938-0910.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NOMNC Form Instructions - 2010 - 508.doc	Instruction
CMS-10095-NOMNC Notice of Medicare Non-Coverage NOMNC508 - 2010.doc	Form
CMS-10095-NOMNC-SP Notificaci?n de Medicare de Terminaci?n de Cobertura CMS10095-NOMNC508-2010 spa.doc	Form
NOMNCforminstructionstrackchanges508.docx NOMNCforminstructionstrackchanges508	IC Document
NOMNCtrackchanges508.docx NOMNCtrackchanges508	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.624(b)(1) 42 CFR 422.626(e)(1)

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			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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,915

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	Previously Approved
Annual Number of Responses for this IC	80,628	80,628
Annual IC Time Burden (Hours)	20,157	20,157
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.