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

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

OMB: 0938-0566

IC ID: 8163

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Instruction
Form
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IC Document
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Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408
 
No Modified
 
Mandatory
 
42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-R-131 Notificaci?n previa de NO-cobertura al beneficiario (ABN) 508spanishabnwatermarked.pdf Yes Yes Paper Only
Form Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) 508ABNwatermarked.pdf Yes No Paper Only
Instruction ABNinstructions2012change(clean).docx Yes No Fillable Fileable

Health Health Care Services

 

1,326,282 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 43,725,850 0 0 0 0 43,725,850
Annual IC Time Burden (Hours) 5,099,309 0 0 0 0 5,099,309
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
2011ABN508trackchanges 2011ABN508trackchanges.docx 01/05/2011
2011ABNFormInstructions508trackchanges 2011ABNFormInstructions508trackchanges.doc 01/05/2011
2011spanishabn508trackchanges 2011spanishabn508trackchanges.doc 01/05/2011
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