Information Collection

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

IC 8163 under ICR 202211-0938-012 · OMB 0938-0566.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0566 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.