Information Collection

Creditable Coverage Disclosure To Cms On-line Form And Instructions : Cms-10198

IC 46152 under ICR 200611-0938-010 · OMB 0938-1013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10198 CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form
CMS-10198 2006.10.20 CCtoCMSInstructions.doc	Instruction
CMS-10198 DIsclosure to CMS Web Page CMS-10198 2006.10.16 Discl to CMS WebPage Screen Shots.doc	Form

IC Title:

CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198

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 423.56e

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10198	DIsclosure to CMS Web Page	CMS-10198 2006.10.16 Discl to CMS WebPage Screen Shots.doc		Yes	Yes	Paper Only
Instruction			CMS-10198 2006.10.20 CCtoCMSInstructions.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 440,613

Number of Respondents for Small Entity: 37,697

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	445,019	445,019
Annual IC Time Burden (Hours)	35,602	35,602
Annual IC Cost Burden (Dollars)	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.