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End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration (CMS-2728)
OMB: 0938-0046
IC ID: 7806
OMB.report
HHS/CMS
OMB 0938-0046
ICR 202402-0938-004
IC 7806
( )
Documents and Forms
Document Name
Document Type
Form CMS-2728
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....
Form
Form CMS-2728
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....
Form
CMS-2728 ESRD Medical Evidence Report
CMS-2728 508 SOGI revisions- clean.docx
Form
CMS-2728 ESRD Medical Evidence Report
CMS-2728 508 SOGI revisions- clean.docx
Form
CMS-2728 508 SOGI revisions- redline.docx
CMS-2728 Redline
IC Document
CMS-2728 508 SOGI revisions- redline.docx
CMS-2728 Redline
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 405.2133
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-2728
ESRD Medical Evidence Report
CMS-2728 508 SOGI revisions- clean.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
7,828
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
138,000
0
0
0
0
138,000
Annual IC Time Burden (Hours)
172,500
0
0
0
0
172,500
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CMS-2728 Redline
CMS-2728 508 SOGI revisions- redline.docx
02/09/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.