IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR Sections 411.20-411.206

Documents and Forms

Document Name Document Type
Form CMS-R-137 IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR Sections 411.20-411.206 Form and Instruction
CMS-R-137 DMI DM_Instructions_Booklet.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR Sections 411.20-411.206	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411 42 CFR 423.462

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-137	DMI	DM_Instructions_Booklet.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 280,028	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	280,028	-46,569	326,597
Annual IC Time Burden (Hours)	1,629,763	-271,032	1,900,795
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.