Information Collection

Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

IC 258292 under ICR 202512-0938-015 · OMB 0938-1444.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ANOC.docx	Instruction
CH 1 EOC.docx	Instruction
CH 2 EOC.docx	Instruction
Ch 3 EOC.docx	Instruction
CH 4 EOC.docx	Instruction
CH 5 EOC.docx	Instruction
CH 6 EOC.docx	Instruction
CH 7 EOC.docx	Instruction
CH 8 EOC.docx	Instruction
CH 9 EOC.docx	Instruction
CH 10 EOC.docx	Instruction
CH 11 EOC.docx	Instruction
CH 12 EOC.docx	Instruction
NTTCHIDSNPANOCCY202402272023.DOCX	Instruction
NTTCHIDSNPCH1CY202402272023.DOCX	Instruction
NTTCHIDSNPCH2CY202402272023.DOCX	Instruction
NTTCHIDSNPCH3CY202402272023.DOCX	Instruction
NTTCHIDSNPCH4CY202402272023.DOCX	Instruction
NTTCHIDSNPCH5CY202402272023.DOCX	Instruction
NTTCHIDSNPCH6CY202402272023.DOCX	Instruction
NTTCHIDSNPCH7CY202402272023.DOCX	Instruction
NTTCHIDSNPCH8CY202402272023.DOCX	Instruction
NTTCHIDSNPCH9CY202402272023.DOCX	Instruction
NTTCHIDSNPCH10CY202402272023.DOCX	Instruction
NTTCHIDSNPCH11CY202402272023.DOCX	Instruction
NTTCHIDSNPCH12CY202402272023.DOCX	Instruction
NT ANOC compare 06182025.docx ANOC Track Change version	IC Document
CH 1 compare 06162025.docx Ch. 1 Track Change version	IC Document
CH 2 compare 06162025.docx Ch. 2 Track Change version	IC Document
Ch 3 compare 06162025.docx Ch. 3 Track Change version	IC Document
CH 4 compare 06162025.docx Ch. 4 Track Change version	IC Document
CH 5 compare 06162025.docx Ch. 5 Track Change version	IC Document
CH 6 compare 06122025.docx Ch. 6 Track Change version	IC Document
CH 7 compare 06122025.docx Ch. 7 Track Change version	IC Document
CH 8 compare 06122025.docx Ch. 8 Track Change version	IC Document
CH 9 compare 06122025.docx Ch. 9 Track Change version	IC Document
CH 10 compare 06122025.docx Ch. 10 Track Change version	IC Document
CH 11 compare 06122025.docx Ch. 11 Track Change version	IC Document
CH 12 compare 06122025.docx Ch. 12 Track Change version	IC Document
Appendix A.docx Appendix A (added to ANOC)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.128 42 CFR 422.111

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Electronic Capability
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable
Instruction	No	Fillable Printable

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: 109

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	109	62	47
Annual IC Time Burden (Hours)	1,308	744	564
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ANOC Track Change version		12/11/2025
Ch. 1 Track Change version		12/11/2025
Ch. 2 Track Change version		12/11/2025
Ch. 3 Track Change version		12/11/2025
Ch. 4 Track Change version		12/11/2025
Ch. 5 Track Change version		12/11/2025
Ch. 6 Track Change version		12/11/2025
Ch. 7 Track Change version		12/11/2025
Ch. 8 Track Change version		12/11/2025
Ch. 9 Track Change version		12/11/2025
Ch. 10 Track Change version		12/11/2025
Ch. 11 Track Change version		12/11/2025
Ch. 12 Track Change version		12/11/2025
Appendix A (added to ANOC)		12/11/2025

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

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