OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Notice of Provider Non-Coverage (CMS-10123)

IC 8809 under ICR 202407-0938-011 · OMB 0938-0953.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Notice of Provider Non-Coverage (CMS-10123)
 
No Modified
 
Mandatory
 
42 CFR 405.1202 42 CFR 405.1200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction NOMNC_instructions_2024_.docx No   Printable Only
Form CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNC_2024_.docx No   Fillable Printable
Form CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanish] NOMNC_2024_Spanish_.docx No   Fillable Printable

Health Health Care Services

 

26,399 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 21,000,000 0 15,279,004 0 0 5,720,996
Annual IC Time Burden (Hours) 3,500,000 0 2,546,501 0 0 953,499
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.