Information Collection

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

IC 46153 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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: 5,634	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	5,634	5,634
Annual IC Time Burden (Hours)	1,916	1,916
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.