Information Collection

Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)

IC 8175 under ICR 201612-0938-023 · OMB 0938-0573.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0573 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-138 Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)	Form
Board Rules 2016-07-21.pdf	Other-Board Rules
CMS-R-138 Statewide Application 2018 Statewide Application.pdf	Form
CMS-R-138 Statewide Affidavit 2018 Statewide Affidavit.pdf	Form
CMS-R-138 Individual Application 2018 Individual Application.pdf	Form
CMS-R-138 Individual - Special Access (Driving Time) 2018 Individual - Special Access (Driving Time).pdf	Form
CMS-R-138 Individual - Special Access (Distance) 2018 Individual - Special Access (Distance).pdf	Form
CMS-R-138 Individual - Proximity (Employee Commuting Pattern) 2018 Individual - Proximity (Employee Commuting Pattern).pdf	Form
CMS-R-138 Individual - Proximity (Distance) 2018 Individual - Proximity (Distance).pdf	Form
CMS-R-138 Group Application 2018 Group Application.pdf	Form and Instruction

Information Collection (IC) Details

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IC Title:

Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 412.232 42 CFR 412.230 42 CFR 412.234 42 CFR 412.252 42 CFR 412.256 42 CFR 412.262 42 CFR 412.268 42 CFR 412.278

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-138	Statewide Application	2018 Statewide Application.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-138	Statewide Affidavit	2018 Statewide Affidavit.pdf	Yes	No	Fillable Fileable
Form	CMS-R-138	Individual Application	2018 Individual Application.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-138	Individual - Special Access (Driving Time)	2018 Individual - Special Access (Driving Time).pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-138	Individual - Special Access (Distance)	2018 Individual - Special Access (Distance).pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-138	Individual - Proximity (Employee Commuting Pattern)	2018 Individual - Proximity (Employee Commuting Pattern).pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-138	Individual - Proximity (Distance)	2018 Individual - Proximity (Distance).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-138	Group Application	2018 Group Application.pdf	Yes	Yes	Fillable Printable
Other-Board Rules			Board Rules 2016-07-21.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

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Number of Respondents: 300

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 %

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	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

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