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

IC 46153 under ICR 200706-0938-003 · OMB 0938-1013.

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CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.56e

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
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

Health Health Care Services

 

5,634 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,634 0 0 0 0 5,634
Annual IC Time Burden (Hours) 1,916 0 0 0 0 1,916
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.