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

Medicare Geographic Classification Review Board Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256

OMB: 0938-0573

IC ID: 8175

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Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)
 
No Unchanged
 
Voluntary
 
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

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

300 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 300 0 0 0 0 300
Annual IC Time Burden (Hours) 300 0 0 0 0 300
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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