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Federal forms, ICRs, and supporting documents

Information Collection

Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

IC 184965 under ICR 201112-0938-003 · OMB 0938-0953.

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Instruction
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Information Collection (IC) Details

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Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 405.1200 42 CFR 405.1202

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMMS-10124 Detailed Explanation of Non-coverage 508_DENCcombined508.pdf Yes No Fillable Fileable
Instruction 508_DENC combinednstructions508.pdf Yes No Fillable Fileable
Form CMS-10124 Detailed Explanation of Non-coverage CMS10124spanish.docx Yes No Fillable Fileable

Health Health Care Services

 

25,655 0
   
Individuals or Households
 
   0 %

  Approved 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 25,655 0 0 0 0 25,655
Annual IC Time Burden (Hours) 42,232 0 0 0 0 42,232
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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