Information Collection

"Important Message From Medicare" Title XVIII Section 1866(a)(1)(M), 42 CFR Section 466.78, 489.20, 489.34, 489.27, 411.404, 4121.42, and 417.400, Section 422.620

IC 8305 under ICR 200009-0938-012 · OMB 0938-0692.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0692 can be found here:

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Information Collection (IC) Details

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IC Title:	"Important Message From Medicare" Title XVIII Section 1866(a)(1)(M), 42 CFR Section 466.78, 489.20, 489.34, 489.27, 411.404, 4121.42, and 417.400, Section 422.620	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-193				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,293	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	11,000,000	11,000,000
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

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Title	Document	Date Uploaded

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