Information Collection

Notice of Provider Non-Coverage (CMS-10123)

IC 8809 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10123 Notice of Provider Non-Coverage (CMS-10123)	Form
NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf	Instruction
NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf	Instruction
CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNCenglishfinal2017v508 (rev 05-02-2018 by OSORA PRA) (3).pdf	Form
CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNCenglishfinal2017v508 (rev 05-02-2018 by OSORA PRA) (3).pdf	Form
CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanis NOMNCspanishfinalword (rev 05-02-2018 by OSORA PRA).docx	Form
CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanis NOMNCspanishfinalword (rev 05-02-2018 by OSORA PRA).docx	Form

IC Title:

Notice of Provider Non-Coverage (CMS-10123)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.1202 42 CFR 405.1200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Instruction			NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf	No	Printable Only
Form	CMS-10123	Notice of Medicare Non-Coverage (NOMNC) [English]	NOMNCenglishfinal2017v508 (rev 05-02-2018 by OSORA PRA) (3).pdf	No	Fillable Printable
Form	CMS-10123	NotificaciÃ³n de Medicare de No-Cobertura (NOMNC) [Spanish]	NOMNCspanishfinalword (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: 26,535

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,720,996	-270,009	5,991,005
Annual IC Time Burden (Hours)	953,499	-45,002	998,501
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.