Information Collection

Beneficiaries

IC 203013 under ICR 201410-0938-011 · OMB 0938-1192.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1192 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10406 Beneficiaries	Form and Instruction
CMS-10406 Instrument CMS-10406.Instrument.docx	Form and Instruction

IC Title:

Beneficiaries

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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-10406	Instrument	CMS-10406.Instrument.docx		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	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.