View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Notice of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003)
 
No Modified
 
Mandatory
 
42 CFR 422.568

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS 10003-NDMC Yes No Fillable Printable
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Form CMS 10003-NDP Yes No Fillable Printable
Form CMS-10003-NDMC-SP Yes No Fillable Printable
Form CMS-10003-NDP-SP Yes No Fillable Printable

Health Health Care Services

 

740 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 1,168,368 0 0 0 0 1,168,368
Annual IC Time Burden (Hours) 194,728 0 0 0 0 194,728
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
NDPforminstructionstrackchanges508 07/16/2010
NDMCforminstructionstrackchanges508 07/16/2010
NDP - 2010 - 508--07-21-10-Track Changes 07/23/2010
NDMC - 2010 - 508--07-21-10-Track Changes 07/23/2010
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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