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Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)
 
No Modified
 
Mandatory
 
42 CFR 422.624(b)(1) 42 CFR 422.626(e)(1)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Yes No Printable Only
Form CMS-10095-NOMNC Yes No Fillable Printable
Form CMS-10095-NOMNC-SP Yes No Fillable Printable

Health Health Care Services

 

24,915 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 80,628 0 0 0 0 80,628
Annual IC Time Burden (Hours) 20,157 0 0 0 0 20,157
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
NOMNCforminstructionstrackchanges508 07/30/2010
NOMNCtrackchanges508 07/30/2010
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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