Information Collection

Federal Funding of Emergency Health Services (Sec. 1011): Enrollment Application

IC 8776 under ICR 200408-0938-007 · OMB 0938-0929.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0929 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Federal Funding of Emergency Health Services (Sec. 1011): Enrollment Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10115				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 62,500	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 Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	31,250	31,250
Annual IC Cost Burden (Dollars)	0	0

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.