Information Collection

Hospital Discharges Detailed Notice of Discharge

IC 179807 under ICR 202212-0938-014 · OMB 0938-1019.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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
CMS-10065/10066 Detailed Notice of Discharge CMS10066_DND_Spanish_2022.docx	Form and Instruction
CMS-10065/10066 Detailed Notice of Discharge CMS10066_DND_Spanish_2022.docx	Form and Instruction

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 405.1206 42 CFR 422.622

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available 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
Form and Instruction	CMS-10065/10066	Detailed Notice of Discharge	CMS10066_DND_Spanish_2022.docx	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 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	44,712	44,712
Annual IC Time Burden (Hours)	44,712	44,712
Annual IC Cost Burden (Dollars)	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.