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Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)
Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID) (CMS-10798)
OMB: 0938-1428
IC ID: 254490
OMB.report
HHS/CMS
OMB 0938-1428
ICR 202207-0938-003
IC 254490
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1428 can be found here:
2023-02-16 - No material or nonsubstantive change to a currently approved collection
2023-02-14 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-10798
Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)
Form and Instruction
CMS-10798 CMS-10798 Application for Part B Immunosuppressive Drug
CMS-10798 Application for Part B Immunosuppressive Drug Coverage_508.pdf
Form and Instruction
CMS-10798 CMS-10798 Application for Part B Immunosuppressive Drug
CMS-10798 Application for Part B Immunosuppressive Drug Coverage_508.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 407.1(a)(6)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10798
CMS-10798 Application for Part B Immunosuppressive Drug Coverage_508
CMS-10798 Application for Part B Immunosuppressive Drug Coverage_508.pdf
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
767
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
767
767
0
0
0
0
Annual IC Time Burden (Hours)
128
128
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.