Information Collection

Medicare Change of Status Notice (MCSN)

IC 264658 under ICR 202410-0938-018 · OMB 0938-1467.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10868 Medicare Change of Status Notice (MCSN)	Form
Form CMS-10868 Medicare Change of Status Notice (MCSN) Medicare Change of Status Notice (MCSN)	Form
Form CMS-10868 Aviso de Cambio de Estado de Medicare Medicare Change of Status Notice (MCSN)	Form
Form CMS-10868 Medicare Change of Status Notice (MCSN) (Chinese) Medicare Change of Status Notice (MCSN)	Form
Form CMS-10868 Medicare Change of Status Notice (MCSN) (Korean) Medicare Change of Status Notice (MCSN)	Form
Form CMS-10868 Medicare Change of Status Notice (MCSN) (Vietnamese) Medicare Change of Status Notice (MCSN)	Form
10868-MCSN_Provider_Instructions_508.docx	Instruction
10868-MCSN_Provider_Instructions_508.docx	Instruction
MCSN_Spanish_Instructions.pdf.docx	Instruction
MCSN_Spanish_Instructions.pdf.docx	Instruction
CMS-10868 Medicare Change of Status Notice (MCSN) 10868-MedicareChangeofStatusNotice (MCSN_English)-508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) 10868-MedicareChangeofStatusNotice (MCSN_English)-508.docx	Form
CMS-10868 Aviso de Cambio de Estado de Medicare 10868-MedicareChangeofStatusNotice (MCSN_Spanish)_508.docx	Form
CMS-10868 Aviso de Cambio de Estado de Medicare 10868-MedicareChangeofStatusNotice (MCSN_Spanish)_508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) (Chinese) 10868-MedicareChangeofStatusNotice (MCSN_Chinese)_508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) (Chinese) 10868-MedicareChangeofStatusNotice (MCSN_Chinese)_508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) (Korean) 10868-MedicareChangeofStatusNotice (MCSN_Korean)_508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) (Korean) 10868-MedicareChangeofStatusNotice (MCSN_Korean)_508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) (Vietnamese) 10868-MedicareChangeofStatusNotice (MCSN_Vietnamese)_508.docx	Form
CMS-10868 Medicare Change of Status Notice (MCSN) (Vietnamese) 10868-MedicareChangeofStatusNotice (MCSN_Vietnamese)_508.docx	Form
CMS-10868_Track Changes.pdf Medicare Change of Status Notice Track Change version	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Change of Status Notice (MCSN)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10868	Yes	No	Fillable Fileable
Instruction		Yes	No	Printable Only
Form	CMS-10868	Yes	No	Fillable Fileable
Instruction		Yes	No	Printable Only
Form	CMS-10868	Yes	No	Fillable Fileable
Form	CMS-10868	Yes	No	Fillable Fileable
Form	CMS-10868	Yes	No	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: 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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
Medicare Change of Status Notice Track Change version		11/13/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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