Information Collection

Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10065/10066)

IC 179807 under ICR 201908-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
DND_draft_instructions_v508.pdf	Instruction
CMS-10065/10066 Detailed Notice of Discharge DND_draft_v508.pdf	Form and Instruction

IC Title:

Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10065/10066)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.622 42 CFR 405.1206

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			DND_draft_instructions_v508.pdf		No		Paper Only
Form and Instruction	CMS-10065/10066	Detailed Notice of Discharge	DND_draft_v508.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,140

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	40,303	17,788	22,515
Annual IC Time Burden (Hours)	40,303	17,788	22,515
Annual IC Cost Burden (Dollars)	0	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.