Medicare Advantage Applications

Medicare Advantage Applications

OMB: 0938-0935

IC ID: 8785

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Medicare Advantage Applications
 
No Modified
 
Voluntary
 
42 CFR 422.501

Document Type Form No. Form Name Instrument File URL 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


 

80 0
   
Private Sector Businesses or other for-profits
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 110 0 20 0 0 90
Annual IC Time Burden (Hours) 3,400 0 630 0 0 2,770
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Legal 1 legal-1.doc 08/22/2006
Essential essential.doc 08/22/2006
Cert cert.doc 08/22/2006
Guidelines Guidelines.DOC 08/22/2006
legal 2 legal-2.xls 08/22/2006
Martrix 1 matrix1.doc 08/22/2006
Matrix 2 matrix2.doc 08/22/2006
Matrix matrixadm.DOC 08/22/2006
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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