Information Collection

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.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form and Instruction
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Version) Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Chinese Version) Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Korean Version) Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Vietnamese Version) Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish_.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish_.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_.docx	Form and Instruction
CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_.docx	Form and Instruction
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Ver ABN_Spanish.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Ver ABN_Spanish.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Chinese Ver ABN_Chinese.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Chinese Ver ABN_Chinese.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Korean Vers ABN_Korean.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Korean Vers ABN_Korean.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Vietnamese ABN_Vietnamese.docx	Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Vietnamese ABN_Vietnamese.docx	Form
ABN-Form-Instructions_Redline.pdf Advance Beneficiary Notice Instruction - Track Change version	IC Document
ABN-Form-Instructions_Redline.pdf Advance Beneficiary Notice Instruction - Track Change version	IC Document
ABNEnglish_redline_.pdf Advance Beneficiary Notice Form - Track Change version	IC Document
ABNEnglish_redline_.pdf Advance Beneficiary Notice Form - Track Change version	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-131	Yes	No	Printable Only
Form	CMS-R-131	Yes	No	Fillable Fileable
Form	CMS-R-131	Yes	No	Fillable Fileable
Form	CMS-R-131	Yes	No	Fillable Fileable
Form	CMS-R-131	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: 1,723,755

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	331,715,277	7,767,647	323,947,630
Annual IC Time Burden (Hours)	38,701,221	906,251	37,794,970
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advance Beneficiary Notice Instruction - Track Change version		11/18/2025
Advance Beneficiary Notice Form - Track Change version		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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