Medicare Change of Status Notice (MCSN)

Medicare Change of Status Notice (MCSN) (CMS-10868)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.