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)

Documents and Forms

Document Name Document Type
Form CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID) Form and Instruction
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.pdf Form and Instruction
CMS-10798 Application for Enrollment in Part B Immunosuppressive D CMS-10798-Application.pdf Form and Instruction
CMS-10798.Justification for Collecting Social Security Numbers_508.pdf Justification for Collecting SSNs IC Document
CMS-10798.Justification for Collecting Social Security Numbers_508.pdf Justification for Collecting SSNs IC Document

Information Collection (IC) Details

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:

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.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 %

	Approved	Previously Approved
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

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.