Information Collection

CMS-R-10 Form 83 - Part II (Documenting Advanced Directive)

IC 189099 under ICR 201312-0938-008 · OMB 0938-0610.

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Information Collection (IC) Details

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IC Title:	CMS-R-10 Form 83 - Part II (Documenting Advanced Directive)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 417.436(d)(iii) 42 CFR 422.128 42 CFR 489.102(a)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39,575	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	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	55,000,000	34,732,016	20,267,984
Annual IC Time Burden (Hours)	2,770,250	1,756,851	1,013,399
Annual IC Cost Burden (Dollars)	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.