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

Medicare Advantage Program and Supporting Regulations (CMS-R-267)

OMB: 0938-0753

IC ID: 257871

Documents and Forms
Document Name
Document Type
Other-CMS Model Document: MA Provide
Other-CMS Model Document: MA Provide
Information Collection (IC) Details

View Information Collection (IC)

Proposed Changes (CMS-4201-P, RIN 0938-AU96)
 
No New
 
Mandatory
 

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

Health Health Care Services

 

882 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56,645 0 56,645 0 0 0
Annual IC Time Burden (Hours) 23,190 0 23,190 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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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