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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
ABNForminstructions2012v508.pdf Instruction
CMS-R-131 ABN 508ABN.pdf Form
CMS-R-131 Spanish ABN 508spanishabncorrected.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			ABNForminstructions2012v508.pdf	Yes	No	Printable Only
Form	CMS-R-131	ABN	508ABN.pdf	Yes	No	Fillable Fileable
Form	CMS-R-131	Spanish ABN	508spanishabncorrected.pdf	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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52,967,771	9,241,921	43,725,850
Annual IC Time Burden (Hours)	6,177,101	1,077,792	5,099,309
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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