Information Collection

Phone Surveys of Product/Service for Medicare Payment Validation and Supporting Regulations in 42 CFR, 405.502 (CMS-10112)

IC 8790 under ICR 200805-0938-002 · OMB 0938-0939.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0939 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
10112-instructions.doc	Other-IR Manual
10112-manual.doc	Other-CMS-Manual System

IC Title:

Phone Surveys of Product/Service for Medicare Payment Validation and Supporting Regulations in 42 CFR, 405.502 (CMS-10112)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 405.502

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-IR Manual			10112-instructions.doc		Yes	Yes	Paper Only
Other-CMS-Manual System			10112-manual.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 750

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,000	2,000	2,000
Annual IC Time Burden (Hours)	16,000	0	16,000
Annual IC Cost Burden (Dollars)	0	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.