Information Collection

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

IC 8163 under ICR 201605-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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
ABNForm Instructions2016v508.pdf	Instruction
CMS-R-131 Spanish ABN ABNSpanish2016 v508.pdf	Form
CMS-R-131 Advanced Beneficiary Notice of Noncoverage ABNEnglish2016v508.pdf	Form
Crosswalk Document for Changes to ABN v2016.pdf Crosswalk	IC Document
ABNEnglish2016trackchanges.docx ABN (English) - Track Changes	IC Document
ABNSpanish2016trackchanges.docx ABN (Spanish) - Track Changes	IC Document
ABNForminstructions2016trackchanges.docx ABN (Instructions) - Track Changes	IC Document

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

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	ABNSpanish2016 v508.pdf	Yes	No	Fillable Fileable
Form	CMS-R-131	Advanced Beneficiary Notice of Noncoverage	ABNEnglish2016v508.pdf	Yes	No	Fillable Fileable
Instruction			ABNForm Instructions2016v508.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,540,850

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	63,601,300	10,633,529	52,967,771
Annual IC Time Burden (Hours)	7,420,364	1,243,263	6,177,101
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk Document for Changes to ABN v2016.pdf	05/10/2016
ABN (English) - Track Changes	ABNEnglish2016trackchanges.docx	05/10/2016
ABN (Spanish) - Track Changes	ABNSpanish2016trackchanges.docx	05/10/2016
ABN (Instructions) - Track Changes	ABNForminstructions2016trackchanges.docx	05/10/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.