Information Collection

Proposed Changes (CMS-4201-P, RIN 0938-AU96)

IC 257871 under ICR 202301-0938-006 · OMB 0938-0753.

Documents and Forms

Document Name Document Type
MA Provider Termination Notice model document_12-14-22.pdf Other-CMS Model Document: MA Provide
MA Provider Termination Notice model document_12-14-22.pdf Other-CMS Model Document: MA Provide

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Proposed Changes (CMS-4201-P, RIN 0938-AU96)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-CMS Model Document: MA Provider Termination Notice			MA Provider Termination Notice model document_12-14-22.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 882	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56,645	56,645
Annual IC Time Burden (Hours)	23,190	23,190
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.