View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.2133

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-2728	ESRD Medical Evidence Report	CMS2728i508 revisions- final clean.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,828	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	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	138,000	0	0	0	0	138,000
Annual IC Time Burden (Hours)	172,500	0	0	0	0	172,500
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-2728 instrument - redline	CMS-2728 instrument 508 redline 3-9-23.docx	05/30/2023
Crosswalk redline	CMS-2728 Crosswalk 508 redline 3-9-23.docx	05/30/2023
Crosswalk	CMS-2728 Crosswalk 508 3-9-23 clean.docx	05/30/2023
CMS-2728 redline for Non-sub change	CMS2728i508 revisions- redline v2.docx	11/28/2023

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