Important Message From Medicare

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⚠️ Notice: This information collection may be referencing outdated material.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_10065_IMinstructions_2022_OSORA.pdf Instruction
CMS_10065_IMinstructions_2022_OSORA.pdf Instruction
CMS-100065/10066 Important Message from Medicare CMS-10655_IM_2022_v508_OSORA.pdf Form and Instruction
CMS-100065/10066 Important Message from Medicare CMS-10655_IM_2022_v508_OSORA.pdf Form and Instruction
CMS-10065/10066 Important Message from Medicare CMS10065_IM_Spanish_2022.docx Form and Instruction
CMS-10065/10066 Important Message from Medicare CMS10065_IM_Spanish_2022.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Important Message From Medicare	Agency IC Tracking Number:	CM-CPC

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.1205 42 CFR 422.620

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Instruction			CMS_10065_IMinstructions_2022_OSORA.pdf	No	Paper Only
Form and Instruction	CMS-100065/10066	Important Message from Medicare	CMS-10655_IM_2022_v508_OSORA.pdf	No	Paper Only
Form and Instruction	CMS-10065/10066	Important Message from Medicare	CMS10065_IM_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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	14,042,374	14,042,374
Annual IC Time Burden (Hours)	2,340,396	2,340,396
Annual IC Cost Burden (Dollars)	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.