Information Collection

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

IC 8163 under ICR 201204-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
ABNinstructions2012change(clean).docx	Instruction
CMS-R-131 Notificaci?n previa de NO-cobertura al beneficiario (ABN 508spanishabnwatermarked.pdf	Form
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) 508ABNwatermarked.pdf	Form
2011ABN508trackchanges.docx 2011ABN508trackchanges	IC Document
2011ABNFormInstructions508trackchanges.doc 2011ABNFormInstructions508trackchanges	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
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

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	Previously Approved
Annual Number of Responses for this IC	43,725,850	43,725,850
Annual IC Time Burden (Hours)	5,099,309	5,099,309
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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