Information Collection

HIPAA Administrative Simplification Non-Privacy Enforcement

IC 179072 under ICR 200703-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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-Provacy Complaint Information-11-29-06.DOC	Instruction
CMS-10148 CMS-10148 - HIPAA Non-Privacy Complaint Form CMS-10148.HIPAA Non-Privacy Paper Complaint Form-11-29-06.doc	Form

IC Title:

HIPAA Administrative Simplification Non-Privacy Enforcement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	CMS-10148 - HIPAA Non-Privacy Complaint Form	CMS-10148.HIPAA Non-Privacy Paper Complaint Form-11-29-06.doc		Yes	No	Fillable Printable
Instruction			CMS-10148.HIPAA Non-Provacy Complaint Information-11-29-06.DOC		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 166

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	166	166
Annual IC Time Burden (Hours)	166	166
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.