View Information Collection (IC)

View Information Collection (IC)

IC Title:	Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 412.232 42 CFR 412.230 42 CFR 412.234 42 CFR 412.252 42 CFR 412.256 42 CFR 412.262 42 CFR 412.268 42 CFR 412.278

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-138	Statewide Application	2018 Statewide Application.pdf		Yes	Yes	Fillable Printable
Form	CMS-R-138	Statewide Affidavit	2018 Statewide Affidavit.pdf		Yes	No	Fillable Fileable
Form	CMS-R-138	Individual Application	2018 Individual Application.pdf		Yes	Yes	Fillable Printable
Form	CMS-R-138	Individual - Special Access (Driving Time)	2018 Individual - Special Access (Driving Time).pdf		Yes	Yes	Fillable Fileable
Form	CMS-R-138	Individual - Special Access (Distance)	2018 Individual - Special Access (Distance).pdf		Yes	Yes	Fillable Fileable
Form	CMS-R-138	Individual - Proximity (Employee Commuting Pattern)	2018 Individual - Proximity (Employee Commuting Pattern).pdf		Yes	Yes	Fillable Fileable
Form	CMS-R-138	Individual - Proximity (Distance)	2018 Individual - Proximity (Distance).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-138	Group Application	2018 Group Application.pdf		Yes	Yes	Fillable Printable
Other-Board Rules			Board Rules 2016-07-21.pdf		Yes	No	Fillable Printable

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: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 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	300	0	0	0	0	300
Annual IC Time Burden (Hours)	300	0	0	0	0	300
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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.