Information Collection

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

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of 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					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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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

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.

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