Qualification-Medicare Advantage Application for Coordinated Care Private Fee-For-Service, Regional Preferred Provider Organization, Service Area Expansion for Coordinated Care.......

Qualification-Medicare Advantage Application for Coordinated Care Private Fee-For-Service, Regional Preferred Preferred Provider Organization, Service Area Expansion for Coordinated Care.......

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Qualification-Medicare Advantage Application for Coordinated Care Private Fee-For-Service, Regional Preferred Preferred Provider Organization, Service Area Expansion for Coordinated Care.......	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-10118	Yes	Yes
Form	CMS-10119	Yes	Yes
Form	CMS-10117	Yes	Yes
Form	CMS-10136	Yes	Yes
Form	CMS-10135	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	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
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	20,100	20,100
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.