Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 (CMS-R-131)

Documents and Forms

Document Name Document Type
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish2026_CLEAN_508.pdf Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish2026_CLEAN_508.pdf Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_CLEAN_508.pdf Form and Instruction
CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_CLEAN_508.pdf Form and Instruction
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Ver ABNSpanish2026_508.pdf Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Ver ABNSpanish2026_508.pdf Form

Information Collection (IC) Details

IC Title:	Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage	ABNEnglish2026_CLEAN_508.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-131	Advanced Beneficiary Notice of Non-coverage Instructions	ABN-Form-Instructions_CLEAN_508.pdf	Yes	No	Printable Only
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage (Spanish Version)	ABNSpanish2026_508.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,701,558	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	323,947,630	-58,268,755	382,216,385
Annual IC Time Burden (Hours)	37,794,970	-6,798,216	44,593,186
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.