Information Collection

Data Collection for Medicare Beneficiaries Receiving Implantable Cardioverter-defibrillators for Primary Prevention of Sudden Cardiac Death

IC 8827 under ICR 201705-0938-001 · OMB 0938-0967.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ICDv2CodersDataDictionary22.pdf	Instruction
CMS-10151 ICD Registry Form v 2.2 ICD_v2_DataCollectionForm_GenLeads_2 2_508 with updated PRA disclosure and expiration.pdf	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			ICDv2CodersDataDictionary22.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10151	ICD Registry Form v 2.2	ICD_v2_DataCollectionForm_GenLeads_2 2_508 with updated PRA disclosure and expiration.pdf		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: 1,600

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	80,000	80,000
Annual IC Time Burden (Hours)	20,000	20,000
Annual IC Cost Burden (Dollars)	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.