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Federal forms, ICRs, and supporting documents

Information Collection

Medicare Advantage & Part D Disenrollment Requests Through 1-800-MEDICARE (CMS-R-257)

IC 8428 under ICR 200811-0938-001 · OMB 0938-0741.

Documents and Forms
Document Name
Document Type
Other-Script
Information Collection (IC) Details

View Information Collection (IC)

Medicare Advantage & Part D Disenrollment Requests Through 1-800-MEDICARE (CMS-R-257)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Script Attmt B_gen-disenrollment_script_7-10-08.doc Yes Yes Paper Only

Health Health Care Services

 

117,000 0
   
Individuals or Households
 
   0 %

  Approved 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 117,000 67,000 0 0 0 50,000
Annual IC Time Burden (Hours) 19,539 16,239 0 0 0 3,300
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.