Information Collection

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

IC 254490 under ICR 202302-0938-010 · OMB 0938-1428.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1428 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)	Form and Instruction
CMS-10798 Application for Enrollment in Part B Immunosuppressive D CMS-10798 Application (10-19-22).pdf	Form and Instruction
CMS-10798.Justification for Collecting Social Security Numbers_508.pdf Justification for Collecting SSNs	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407.1(a)(6)

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
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 767

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	767	767
Annual IC Time Burden (Hours)	128	128
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.