OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Voluntarily Withdrawal (from the Medicare Program)

IC 240708 under ICR 202103-0938-020 · OMB 0938-1377.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Voluntarily Withdrawal (from the Medicare Program)
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
42 CFR 424,500  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program CMS-855B - Medicare Enrollment Application with Opioid Treatment Program - 30-day.pdf Yes No Fillable Printable

Health Health Care Services

 

3,931 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 3,931 0 0 0 0 3,931
Annual IC Time Burden (Hours) 1,966 0 0 0 0 1,966
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.