Information Collection

Beneficiary Notification

IC 242933 under ICR 202305-0938-016 · OMB 0938-1388.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10728 Beneficiary Notification	Form and Instruction
CMS-10728 Beneficiary Notification Value in Treatment_OUD Medicare Beneficiary Notice_Final.docx	Form and Instruction
CMS-10728 Beneficiary Notification Value in Treatment_OUD Medicare Beneficiary Notice_Final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 1866F (To search for a specific CFR, visit the Code of Federal Regulations.)

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-10728	Beneficiary Notification	Value in Treatment_OUD Medicare Beneficiary Notice_Final.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Master Demonstration, Evaluation, and Research Studies for the Office of Research Development and Information (DERS)

FR Citation: 83 FR 6591

Number of Respondents: 47

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	47	-53	100
Annual IC Time Burden (Hours)	4	-46	50
Annual IC Cost Burden (Dollars)	0	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.