Information Collection

Important Message From Medicare

IC 237581 under ICR 202512-0938-011 · OMB 0938-1019.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-100065/10066 Important Message from Medicare Important Message From Medicare	Form and Instruction
Form CMS-10065/10066 Important Message from Medicare Important Message From Medicare	Form and Instruction
IM Instructions_2025_Updtd_.docx	Instruction
IM Instructions_2025_Updtd_.docx	Instruction
CMS-100065/10066 Important Message from Medicare IM_CMS-10065_2025Updtd_.docx	Form and Instruction
CMS-100065/10066 Important Message from Medicare IM_CMS-10065_2025Updtd_.docx	Form and Instruction
CMS-10065/10066 Important Message from Medicare CMS10065_IM_Spanish_2022.docx	Form and Instruction
CMS-10065/10066 Important Message from Medicare CMS10065_IM_Spanish_2022.docx	Form and Instruction
CMS-10065_IM_2025_REDLINED.pdf Track Change - Important Message	IC Document
CMS-10065_IM_2025_REDLINED.pdf Track Change - Important Message	IC Document
IM Instructions_2025_redline_v1.pdf Track Change - Instructions Important Message	IC Document
IM Instructions_2025_redline_v1.pdf Track Change - Instructions Important Message	IC Document

IC Title:

Agency IC Tracking Number:

CM-CPC

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.620Â 42 CFR 405.1205Â Â Â Â

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Instruction		No	Paper Only
Form and Instruction	CMS-100065/10066	No	Paper Only
Form and Instruction	CMS-10065/10066	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,995

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	25,300,000	11,257,626	14,042,374
Annual IC Time Burden (Hours)	4,216,667	1,876,271	2,340,396
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - Important Message		12/16/2025
Track Change - Instructions Important Message		12/16/2025

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].