Information Collection

Medicare Advantage Applications

IC 8785 under ICR 200608-0938-002 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10135 Medicare Advantage Applications	Form and Instruction
CMS-10117 CCP Application CCP Application.doc	Form and Instruction
CMS-10136 MSA Application MSA Application.DOC	Form and Instruction
CMS-10118 MSA Application PFFS Application.doc	Form and Instruction
CMS-10119 RPPO Application RPPO.DOC	Form and Instruction
CMS-10135 SAE Application and Instructions SAE Appplication.DOC	Form and Instruction
legal-1.doc Legal 1	IC Document
essential.doc Essential	IC Document
cert.doc Cert	IC Document
Guidelines.DOC Guidelines	IC Document
legal-2.xls legal 2	IC Document
matrix1.doc Martrix 1	IC Document
matrix2.doc Matrix 2	IC Document
matrixadm.DOC Matrix	IC Document

IC Title:

Medicare Advantage Applications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.501

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10135	SAE Application and Instructions	SAE Appplication.DOC	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10117	CCP Application	CCP Application.doc	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10136	MSA Application	MSA Application.DOC	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10118	MSA Application	PFFS Application.doc	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10119	RPPO Application	RPPO.DOC	Yes	Yes	Fillable Printable

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	110	20	90
Annual IC Time Burden (Hours)	3,400	630	2,770
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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