Information Collection

Detailed Explanation of Non-Coverage (CMS-10124)

IC 184965 under ICR 202012-0938-012 · OMB 0938-0953.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0953 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf	Instruction
DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf	Instruction
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English final2017v508 (rev 05-02-2018 by OSORA PRA).pdf	Form
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English final2017v508 (rev 05-02-2018 by OSORA PRA).pdf	Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC Spanishfinalword (rev 05-02-2018 by OSORA PRA).docx	Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC Spanishfinalword (rev 05-02-2018 by OSORA PRA).docx	Form

IC Title:

Detailed Explanation of Non-Coverage (CMS-10124)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.1200 42 CFR 405.1202

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Instruction			DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf	No	Fillable Printable
Form	CMS-10124	Detailed Explanation of Non-coverage (DENC) [English]	DENC English final2017v508 (rev 05-02-2018 by OSORA PRA).pdf	No	Fillable Printable
Form	CMS-10124	ExplicaciÃ³n Detallada No-Cobertura (DENC) [Spanish]	DENC Spanishfinalword (rev 05-02-2018 by OSORA PRA).docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27,232

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	151,400	0	65,461	85,939
Annual IC Time Burden (Hours)	189,250	-164,144	245,970	107,424
Annual IC Cost Burden (Dollars)	0	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.