Information Collection

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

IC 8163 under ICR 201506-0938-012 · OMB 0938-0566.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0566 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
CMS-R-131.ABNForminstructions2015changesv508.pdf	Instruction
CMS-R-131 Spanish ABN 508spanishabncorrected.pdf	Form
CMS-R-131 Advanced Beneficiary Notice of Noncoverage CMS-R-131.ABN instrument (REVISED 6-25-15).pdf	Form

IC Title:

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131	Spanish ABN	508spanishabncorrected.pdf	Yes	No	Fillable Fileable
Form	CMS-R-131	Advanced Beneficiary Notice of Noncoverage	CMS-R-131.ABN instrument (REVISED 6-25-15).pdf	Yes	No	Fillable Fileable
Instruction			CMS-R-131.ABNForminstructions2015changesv508.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,326,282

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	52,967,771	52,967,771
Annual IC Time Burden (Hours)	6,177,101	6,177,101
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.