Information Collection

Notice of Provider Non-Coverage (CMS-10123)

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NOMNC_instructions_2024_.docx	Instruction
NOMNC_instructions_2024_.docx	Instruction
CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNC_2024_.docx	Form
CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNC_2024_.docx	Form
CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanis NOMNC_2024_Spanish_.docx	Form
CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanis NOMNC_2024_Spanish_.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.1202 42 CFR 405.1200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available 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	NotificaciÃ³n de Medicare de No-Cobertura (NOMNC) [Spanish]	NOMNC_2024_Spanish_.docx	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: Private Sector

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

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