Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)

Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID) (CMS-10798)

OMB: 0938-1428

IC ID: 254490

Information Collection (IC) Details

View Information Collection (IC)

Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 407.1(a)(6)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage CMS-10798 Application (10-19-22).pdf Yes No Fillable Fileable

Health Health Care Services

 

767 0
   
Individuals or Households
 
   0 %

  Approved 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 767 767 0 0 0 0
Annual IC Time Burden (Hours) 128 128 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Justification for Collecting SSNs CMS-10798.Justification for Collecting Social Security Numbers_508.pdf 10/21/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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