Information Collection

Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066)

IC 179807 under ICR 201607-0938-010 · OMB 0938-1019.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1019 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10066 Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066) Form and Instruction
CMS-10066 Detailed Notice of Discharge DND2016v508.pdf Form and Instruction
CMS-10066 Aviso Detallado Sobre Dado De Alta DNDSpanish2016v508.pdf Form and Instruction
DND2016trackchanges.docx DND (English) Track Changes IC Document
DNDSpanish2016v508.pdf DND (Spanish) Track Changes IC Document
DND Crosswalk Document for Changes2016 [rev July 2016].pdf Crosswalk - DND IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.1206 42 CFR 422.622

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10066	Detailed Notice of Discharge	DND2016v508.pdf		No		Paper Only
Form and Instruction	CMS-10066	Aviso Detallado Sobre Dado De Alta	DNDSpanish2016v508.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	22,515	9,663	12,852
Annual IC Time Burden (Hours)	22,515	9,663	12,852
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
DND (English) Track Changes	DND2016trackchanges.docx	07/18/2016
DND (Spanish) Track Changes	DNDSpanish2016v508.pdf	07/18/2016
Crosswalk - DND	DND Crosswalk Document for Changes2016 [rev July 2016].pdf	07/18/2016

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