Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

Advance Beneficiary Notice of Non-Coverage (ABN) (CMS-R-131)

Documents and Forms

Document Name Document Type
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish_.docx Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_.docx Form and Instruction
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Ver ABN_Spanish.docx Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Chinese Ver ABN_Chinese.docx Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Korean Vers ABN_Korean.docx Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Vietnamese ABN_Vietnamese.docx Form
ABN-Form-Instructions_Redline.pdf Advance Beneficiary Notice Instruction - Track Change version IC Document
ABNEnglish_redline_.pdf Advance Beneficiary Notice Form - Track Change version IC Document

Information Collection (IC) Details

IC Title:	Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage	ABNEnglish_.docx	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-131	Advanced Beneficiary Notice of Non-coverage Instructions	ABN-Form-Instructions_.docx	Yes	No	Printable Only
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage (Spanish Version)	ABN_Spanish.docx	Yes	No	Fillable Fileable
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage (Chinese Version)	ABN_Chinese.docx	Yes	No	Fillable Fileable
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage (Korean Version)	ABN_Korean.docx	Yes	No	Fillable Fileable
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage (Vietnamese Version)	ABN_Vietnamese.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,723,755	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 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	331,715,277	7,767,647	323,947,630
Annual IC Time Burden (Hours)	38,701,221	906,251	37,794,970
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Advance Beneficiary Notice Instruction - Track Change version	ABN-Form-Instructions_Redline.pdf	11/18/2025
Advance Beneficiary Notice Form - Track Change version	ABNEnglish_redline_.pdf	11/18/2025

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