Information Collection

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

IC 46153 under ICR 200706-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
20070529 CMS-10198 Discl to CMS Instructions Screen Shots No redline.doc	Instruction
CMS-10198 DIsclosure to CMS Web Page CMS-10198 2006.10.16 Discl to CMS WebPage Screen Shots.doc	Form
CMS-10198 Disclosure to CMS Form 20070518 Updated Disclosure to CMS Form 06.01.07.doc	Form
20070529 CMS-10198 Discl to CMS Instructions Screen Shots Redline.doc Redline Disclosure to CMS Form Instructions	IC Document

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: Modified

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	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
Form	CMS-10198	Disclosure to CMS Form	20070518 Updated Disclosure to CMS Form 06.01.07.doc	Yes	Yes	Paper Only
Instruction			20070529 CMS-10198 Discl to CMS Instructions Screen Shots No redline.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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
Redline Disclosure to CMS Form Instructions	20070529 CMS-10198 Discl to CMS Instructions Screen Shots Redline.doc	05/31/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.