Information Collection

Model Creditable Coverage Disclosure Notices (CMS-10182)

IC 8852 under ICR 200610-0938-010 · OMB 0938-0990.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Model Creditable Coverage Disclosure Notices (CMS-10182)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56

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
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: 444,613

Number of Respondents for Small Entity: 37,697

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,182,671	-42,502	1,225,173
Annual IC Time Burden (Hours)	508,549	-13,655	522,204
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.