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Federal forms, ICRs, and supporting documents

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
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Instruction
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IC Document
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Information Collection (IC) Details

View Information Collection (IC)

Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
 
No Modified
 
Mandatory
 
42 CFR 423.128 42 CFR 422.111

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction ANOC.docx No   Fillable Printable
Instruction CH 1 EOC.docx No   Fillable Printable
Instruction CH 2 EOC.docx No   Fillable Printable
Instruction Ch 3 EOC.docx No   Fillable Printable
Instruction CH 4 EOC.docx No   Fillable Printable
Instruction CH 5 EOC.docx No   Fillable Printable
Instruction CH 6 EOC.docx No   Fillable Printable
Instruction CH 7 EOC.docx No   Fillable Printable
Instruction CH 8 EOC.docx No   Fillable Printable
Instruction CH 9 EOC.docx No   Fillable Printable
Instruction CH 10 EOC.docx No   Fillable Printable
Instruction CH 11 EOC.docx No   Fillable Printable
Instruction CH 12 EOC.docx No   Fillable Printable
Instruction NTTCHIDSNPANOCCY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH1CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH2CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH3CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH4CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH5CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH6CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH7CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH8CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH9CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH10CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH11CY202402272023.DOCX No   Fillable Printable
Instruction NTTCHIDSNPCH12CY202402272023.DOCX No   Fillable Printable

Health Health Care Services

 

109 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested 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 109 0 62 0 0 47
Annual IC Time Burden (Hours) 1,308 0 744 0 0 564
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
ANOC Track Change version NT ANOC compare 06182025.docx 12/11/2025
Ch. 1 Track Change version CH 1 compare 06162025.docx 12/11/2025
Ch. 2 Track Change version CH 2 compare 06162025.docx 12/11/2025
Ch. 3 Track Change version Ch 3 compare 06162025.docx 12/11/2025
Ch. 4 Track Change version CH 4 compare 06162025.docx 12/11/2025
Ch. 5 Track Change version CH 5 compare 06162025.docx 12/11/2025
Ch. 6 Track Change version CH 6 compare 06122025.docx 12/11/2025
Ch. 7 Track Change version CH 7 compare 06122025.docx 12/11/2025
Ch. 8 Track Change version CH 8 compare 06122025.docx 12/11/2025
Ch. 9 Track Change version CH 9 compare 06122025.docx 12/11/2025
Ch. 10 Track Change version CH 10 compare 06122025.docx 12/11/2025
Ch. 11 Track Change version CH 11 compare 06122025.docx 12/11/2025
Ch. 12 Track Change version CH 12 compare 06122025.docx 12/11/2025
Appendix A (added to ANOC) Appendix A.docx 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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