Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers

Data collection for Medicare Beneficiaries Receiving FDG Positron Emission Tomography (PET) for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and All Other Cancers

OMB: 0938-0968

IC ID: 8828

Information Collection (IC) Details

View Information Collection (IC)

Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10152 PET Facility Registration Form 0938-0968 Form 1.pdf Yes Yes Fillable Fileable
Form CMS-10152 NOPR referring_md_sheet NOPR referring_md_sheet.pdf Yes Yes Fillable Fileable
Form CMS-10152 Case Registration Form 0938-0968 Form 2.pdf Yes Yes Fillable Fileable
Form CMS-10152 Pre-PET Form 0938-0968 Form 3.pdf Yes Yes Fillable Fileable
Form CMS-10152 PET Completion Form 0938-0968 Form 4.pdf Yes Yes Fillable Fileable
Form CMS-10152 Report Submission Form 0938-0968 Form 5.pdf Yes Yes Fillable Fileable
Form CMS-10152 Interpreting Physician Scan Assessment Form 0938-0968 Form 6.pdf Yes Yes Fillable Fileable
Form CMS-10152 Diagnosis of Suspected Osseous Mestasis Form-Post Scan 0938-0968 Form 7.docx Yes Yes Fillable Fileable
Form CMS-10152 Initial Staging Form 0938-0968 Form 8.docx Yes Yes Fillable Fileable
Form CMS-10152 Treatment Monitoring Form-Post Scan 0938-0968 Form 9.docx Yes Yes Fillable Fileable
Form CMS-10152 Restaging Form Post-Scan 0938-0968 Form 10.docx Yes Yes Fillable Fileable

Health Health Care Services

Data Collection Secondary to Coverage Decision System  70 FR 53667

2,000 0
   
Private Sector Businesses or other for-profits
 
   80 %

  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 50,000 0 0 0 50,000 0
Annual IC Time Burden (Hours) 4,167 0 0 0 4,167 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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