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Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)

IC 8175 under ICR 202507-0938-026 · OMB 0938-0573.

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Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138) CM-FFS
 
No Modified
 
Voluntary
 
42 CFR 412.234 42 CFR 412.252 42 CFR 412.256 42 CFR 412.232 42 CFR 412.230 42 CFR 412.262 42 CFR 412.268 42 CFR 412.278

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-R-138 Statewide Application Affadavit statewide-application-affidavit.pdf Yes Yes Fillable Fileable
Form CMS-R-138 Screenshot CMS-R-138 Screenshot MGCRB webpage screenshot 2026-02-04 .png Yes Yes Fillable Fileable

Health Health Care Services

 

850 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 850 0 550 0 300 0
Annual IC Time Burden (Hours) 850 0 550 0 300 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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