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

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.