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Federal forms, ICRs, and supporting documents

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Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

IC 8163 under ICR 202511-0938-004 · OMB 0938-0566.

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Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408
 
No Modified
 
Mandatory
 
42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish_.docx Yes No Fillable Fileable
Form and Instruction CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_.docx Yes No Printable Only
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Version) ABN_Spanish.docx Yes No Fillable Fileable
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Chinese Version) ABN_Chinese.docx Yes No Fillable Fileable
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Korean Version) ABN_Korean.docx Yes No Fillable Fileable
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Vietnamese Version) ABN_Vietnamese.docx Yes No Fillable Fileable

Health Health Care Services

 

1,723,755 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 331,715,277 0 0 7,767,647 0 323,947,630
Annual IC Time Burden (Hours) 38,701,221 0 0 906,251 0 37,794,970
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Advance Beneficiary Notice Instruction - Track Change version ABN-Form-Instructions_Redline.pdf 11/18/2025
Advance Beneficiary Notice Form - Track Change version ABNEnglish_redline_.pdf 11/18/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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