Data Collection for Medicare Beneficiaries Receiving Implantable Cardioverter-defibrillators for Primary Prevention of Sudden Cardiac Death

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0967 can be found here:

Documents and Forms

Document Name Document Type
ICDDataDictionaryv1 0.pdf Instruction
CMS-10151 CMS-10151 Instrument ICD_v2_DataCollectionForm_GenLeads_2 1_508 compliant.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Collection for Medicare Beneficiaries Receiving Implantable Cardioverter-defibrillators for Primary Prevention of Sudden Cardiac Death	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			ICDDataDictionaryv1 0.pdf		Yes	No	Fillable Fileable
Form	CMS-10151	CMS-10151 Instrument	ICD_v2_DataCollectionForm_GenLeads_2 1_508 compliant.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Data Collection Secondary to Coverage Decision System	FR Citation: 70 FR 53667

Number of Respondents: 1,702	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: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	20,424	-29,576	50,000
Annual IC Time Burden (Hours)	139,656	127,156	12,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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