Information Collection

HIPAA Administrative Simplification Non-Privacy Enforcement

IC 8801 under ICR 200612-0938-002 · OMB 0938-0948.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0948 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10148 HIPAA Administrative Simplification Non-Privacy Enforcement	Form
CMS-10148 HIPAA Non-Privacy Paper Complaint Form CMS-10148.REVISED HIPAA Non-Privacy Paper Complaint Form.doc	Form

IC Title:

HIPAA Administrative Simplification Non-Privacy Enforcement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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-10148	HIPAA Non-Privacy Paper Complaint Form	CMS-10148.REVISED HIPAA Non-Privacy Paper Complaint Form.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	500	500
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.