Information Collection

Detailed Explanation of Non-Coverage (CMS-10124)

IC 184965 under ICR 202407-0938-011 · OMB 0938-0953.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] Detailed Explanation of Non-Coverage (CMS-10124)	Form
Form CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] Detailed Explanation of Non-Coverage (CMS-10124)	Form
DENC_instructions_2024_.docx	Instruction
DENC_instructions_2024_.docx	Instruction
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC_2024_.docx	Form
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC_2024_.docx	Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC_2024_Spanish_.docx	Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC_2024_Spanish_.docx	Form

IC Title:

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 405.1200 42 CFR 405.1202

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Instruction		No	Fillable Printable
Form	CMS-10124	No	Fillable Printable
Form	CMS-10124	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26,399

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	369,755	218,355	151,400
Annual IC Time Burden (Hours)	472,305	283,055	189,250
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].