Hospital Discharges Detailed Notice of Discharge

Hospital Notices: IM / DND (CMS-10065/10066)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1019 can be found here:

Documents and Forms

Document Name Document Type
CMS_10066_DNDinstructions_2022_OSORA.pdf Instruction
CMS_10066_DNDinstructions_2022_OSORA.pdf Instruction
CMS-10065/10066 Detailed Notice of Discharge CMS_10066_DND_2022_OSORA.pdf Form and Instruction
CMS-10065/10066 Detailed Notice of Discharge CMS_10066_DND_2022_OSORA.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital Discharges Detailed Notice of Discharge	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS_10066_DNDinstructions_2022_OSORA.pdf		No		Paper Only
Form and Instruction	CMS-10065/10066	Detailed Notice of Discharge	CMS_10066_DND_2022_OSORA.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,312	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	44,712	4,409	40,303
Annual IC Time Burden (Hours)	44,712	4,409	40,303
Annual IC Cost Burden (Dollars)	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.