Information Collection

Medicare Change of Status Notice (MCSN)

IC 264658 under ICR 202401-0938-012 · OMB 0938-1467.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1467 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10868 Medicare Change of Status Notice (MCSN)	Form
MCSN_English_Instructions_drafttoOSORA_508.pdf	Instruction
MCSN_English_Instructions_drafttoOSORA_508.pdf	Instruction
MCSN_Spanish_Instructions_drafttoOSORA_508.pdf	Instruction
MCSN_Spanish_Instructions_drafttoOSORA_508.pdf	Instruction
CMS-10868 Medicare Change of Status Notice (MCSN) MCSN_English_drafttoOSORA_508.pdf	Form
CMS-10868 Medicare Change of Status Notice (MCSN) MCSN_English_drafttoOSORA_508.pdf	Form
CMS-10868 Aviso de Cambio de Estado de Medicare MCSN_Spanish_drafttoOSORA_508.pdf	Form
CMS-10868 Aviso de Cambio de Estado de Medicare MCSN_Spanish_drafttoOSORA_508.pdf	Form

IC Title:

Medicare Change of Status Notice (MCSN)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10868	Medicare Change of Status Notice (MCSN)	MCSN_English_drafttoOSORA_508.pdf	Yes	No	Fillable Fileable
Instruction			MCSN_English_Instructions_drafttoOSORA_508.pdf	Yes	No	Printable Only
Form	CMS-10868	Aviso de Cambio de Estado de Medicare	MCSN_Spanish_drafttoOSORA_508.pdf	Yes	No	Fillable Fileable
Instruction			MCSN_Spanish_Instructions_drafttoOSORA_508.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,162

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 5 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,655	15,655
Annual IC Time Burden (Hours)	2,610	2,610
Annual IC Cost Burden (Dollars)	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.