Information Collection

Qualification Application; Medicare+Choice Application of HMOs, PPOs, & State Licensed PSOs; Medicare+Choice Application for Federally Waived PSOs; Medicare+Choice Application for Medicare..

IC 8097 under ICR 200311-0938-010 · OMB 0938-0470.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0470 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Qualification Application; Medicare+Choice Application of HMOs, PPOs, & State Licensed PSOs; Medicare+Choice Application for Federally Waived PSOs; Medicare+Choice Application for Medicare..	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CMS-901A	Yes	Yes
Form	901C	Yes	Yes
Form	901B	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	55	20	0	35
Annual IC Time Burden (Hours)	5,958	2,458	0	3,500
Annual IC Cost Burden (Dollars)	0	0	-471,000	471,000

Documents for IC

Title	Document	Date Uploaded

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