Information Collection

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

IC 8156 under ICR 201309-0938-013 · OMB 0938-0565.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.