Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193)

Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges: Important Message From Medicare (CMS-R-193)

Documents and Forms

Document Name Document Type
Form CMS-R-193 Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193) Form and Instruction
CMS-R-193 Important Message from Medicare IM2016v508.pdf Form and Instruction
CMS-R-193 Mensaje Importante De Medicare Sobre Sus Derechos SpanishIMv508.pdf Form and Instruction
CrosswalkIM2016 [rev July 2016].pdf Crosswalk IC Document
IM2016trackchanges.docx IM (English) Track Changes IC Document
SpanishIM2016trackchanges.docx IM (Spanish) Track Changes IC Document

Information Collection (IC) Details

IC Title:	Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.620 42 CFR 405.1205

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-193	Important Message from Medicare	IM2016v508.pdf		No		Paper Only
Form and Instruction	CMS-R-193	Mensaje Importante De Medicare Sobre Sus Derechos	SpanishIMv508.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,142	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	23,680,000	3,840,000	19,840,000
Annual IC Time Burden (Hours)	3,404,000	428,000	2,976,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CrosswalkIM2016 [rev July 2016].pdf	07/18/2016
IM (English) Track Changes	IM2016trackchanges.docx	07/18/2016
IM (Spanish) Track Changes	SpanishIM2016trackchanges.docx	07/18/2016

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