Information Collection

Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers

IC 8828 under ICR 201605-0938-013 · OMB 0938-0968.

Documents and Forms

Document Name Document Type
Form CMS-10152 Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers Form and Instruction
CMS-10152 Restaging Form Form 10.docx Form and Instruction
CMS-10152 Treatment Monitoring Form Form 9.docx Form and Instruction
CMS-10152 Restaging Form - Post Scan Form 8.docx Form and Instruction
CMS-10152 Interpreting Physician Scan Assessment Form Form 7.docx Form and Instruction
CMS-10152 Pre-PET Form Form 6.docx Form and Instruction
CMS-10152 Initial Staging Form Form 5.docx Form and Instruction
CMS-10152 PET Completion Form Form 4.docx Form and Instruction
CMS-10152 Report Submission Form Form 3.docx Form and Instruction
CMS-10152 Diagnosis of Suspected Osseous Metastasis Form Form 2.docx Form and Instruction
CMS-10152 PET Facility log-in information Form 1.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10152	Restaging Form	Form 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Treatment Monitoring Form	Form 9.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Restaging Form - Post Scan	Form 8.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Interpreting Physician Scan Assessment Form	Form 7.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Pre-PET Form	Form 6.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Initial Staging Form	Form 5.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	PET Completion Form	Form 4.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Report Submission Form	Form 3.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	Diagnosis of Suspected Osseous Metastasis Form	Form 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10152	PET Facility log-in information	Form 1.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Data Collection Secondary to Coverage Decision System	FR Citation: 70 FR 53667

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,000	-25,000	50,000
Annual IC Time Burden (Hours)	2,083	-2,084	4,167
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.