Information Collection

Conditions for properly opting-out of Medicare (sec. 405.410(b))

IC 178715 under ICR 201511-0938-005 · OMB 0938-0730.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0730 can be found here:

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Information Collection (IC) Details

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IC Title:	Conditions for properly opting-out of Medicare (sec. 405.410(b))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.410(b)

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: 150	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	Previously Approved
Annual Number of Responses for this IC	150	-450	600
Annual IC Time Burden (Hours)	300	-900	1,200
Annual IC Cost Burden (Dollars)	0	0	0

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