Information Collection

Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202

IC 8809 under ICR 201112-0938-003 · OMB 0938-0953.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0953 can be found here:

Documents and Forms

Document Name Document Type
508_NOMNCcombinedinstructions508.pdf Instruction
CMS-10123 Notice of Medicare Non-Coverage 508_NOMNCcombined508.pdf Form
CMS-10123 Notice of Medicare Non-Coverage CMS10123spanish.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.1200 42 CFR 405.1202

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			508_NOMNCcombinedinstructions508.pdf	Yes	No	Fillable Fileable
Form	CMS-10123	Notice of Medicare Non-Coverage	508_NOMNCcombined508.pdf	Yes	No	Fillable Fileable
Form	CMS-10123	Notice of Medicare Non-Coverage	CMS10123spanish.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24,915	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,314,194	5,314,194
Annual IC Time Burden (Hours)	885,699	885,699
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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