Information Collection

Federal Reimbursement Of Emergency Health Services Furnished To Undocumented Aliens (section 1011) Provider Enrollment Application (cms-10115)

IC 37924 under ICR 200804-0938-004 · OMB 0938-0929.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0929 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10115 redline DRAFT Enrollment Form w markupsSSL MED 122007.XLS	Other-Redline Application
CMS-10115 Section 1011 Provider Enrollment Application (Draft) CMS-10115 DRAFT Enrollment Form w-o markups MED 081908.xls	Form and Instruction
JUSTIFICATION for REQUESTING SOC SEC NOS MED + JENN 121907.doc Justification for use of SSN's	IC Document
CMS-10115 SUMMARY OF CHANGES TO 1011 ENROLLMENT FORM MED + JENN 121907.doc Summary of Changes	IC Document

IC Title:

FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115)

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
Other-Redline Application			CMS-10115 redline DRAFT Enrollment Form w markupsSSL MED 122007.XLS		Yes	Yes	Paper Only
Form and Instruction	CMS-10115	Section 1011 Provider Enrollment Application (Draft)	CMS-10115 DRAFT Enrollment Form w-o markups MED 081908.xls		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,000	-52,500	62,500
Annual IC Time Burden (Hours)	4,998	-26,252	31,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for use of SSN's	JUSTIFICATION for REQUESTING SOC SEC NOS MED + JENN 121907.doc	04/09/2008
Summary of Changes	CMS-10115 SUMMARY OF CHANGES TO 1011 ENROLLMENT FORM MED + JENN 121907.doc	04/09/2008

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