Model Creditable Coverage Disclosure Notices (CMS-10182)

Model Creditable Coverage Disclosure Notices

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0990 can be found here:

Documents and Forms

Document Name Document Type
CMS-10182 09.15.06 CC Guidance Updated Final - 09.12.06.doc Instruction
CMS 10182-P Important Notice from[Insert Name of Enity] About Your P CMS-10182 09.15.06 PRA CC disclosure Updated 09.12.06.DOC Form
CMS 10182-CC Individual Creditable Coverage Disclosure Notice CMS-10182 09.15.06 PRA CC disclosure Updated 09.12.06.DOC Form
CMS 10182-NC Individual Non-Creditable Coverage Disclosure Notice CMS-10182 09.15.06 PRA Non-CC disclosure Updated 09.12.06.DOC Form

Information Collection (IC) Details

IC Title:	Model Creditable Coverage Disclosure Notices (CMS-10182)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10182 09.15.06 CC Guidance Updated Final - 09.12.06.doc	Yes	Yes	Printable Only
Form	CMS 10182-P	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare	CMS-10182 09.15.06 PRA CC disclosure Updated 09.12.06.DOC	Yes	Yes	Printable Only
Form	CMS 10182-CC	Individual Creditable Coverage Disclosure Notice	CMS-10182 09.15.06 PRA CC disclosure Updated 09.12.06.DOC	Yes	Yes	Printable Only
Form	CMS 10182-NC	Individual Non-Creditable Coverage Disclosure Notice	CMS-10182 09.15.06 PRA Non-CC disclosure Updated 09.12.06.DOC	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,540	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42,436	42,436
Annual IC Time Burden (Hours)	13,580	13,580
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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