Information Collection

Model Creditable Coverage Disclosure Notices (CMS-10182)

IC 8852 under ICR 200805-0938-003 · OMB 0938-0990.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0990 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10182 09.15.06 CC Guidance Updated Final - 09.12.06.doc	Instruction
Redline Model Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc	Other-Redline CC
Redline Model Non Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc	Other-Redline Non-CC
Redline Model Personalized Disclosure Notice 02.15.07 vs 05.15.08.doc	Other-Redline Personalized
CMS-10182 CC MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE 04.21.08 PRA CC disclosure - Updated for 05 15 08.doc	Form
CMS-10182-P MODEL INDIVIDUAL PERSONALIZED DISCLOSURE NOTICE 04.21.08 PRAModel-Personalized-Disclosure-Notice for 05 15 08.doc	Form
CMS-10182-NC MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTI ~$.21.08 PRA Non-CC disclosure Updated for 05 15 08.doc	Form

IC Title:

Model Creditable Coverage Disclosure Notices (CMS-10182)

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 423.56

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
Instruction			CMS-10182 09.15.06 CC Guidance Updated Final - 09.12.06.doc	Yes	Yes	Printable Only
Form	CMS-10182 CC	MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE	04.21.08 PRA CC disclosure - Updated for 05 15 08.doc	Yes	Yes	Paper Only
Form	CMS-10182-P	MODEL INDIVIDUAL PERSONALIZED DISCLOSURE NOTICE	04.21.08 PRAModel-Personalized-Disclosure-Notice for 05 15 08.doc	Yes	Yes	Paper Only
Form	CMS-10182-NC	MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE	~$.21.08 PRA Non-CC disclosure Updated for 05 15 08.doc	Yes	Yes	Paper Only
Other-Redline CC			Redline Model Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc	Yes	Yes	Paper Only
Other-Redline Non-CC			Redline Model Non Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc	Yes	Yes	Paper Only
Other-Redline Personalized			Redline Model Personalized Disclosure Notice 02.15.07 vs 05.15.08.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 444,613

Number of Respondents for Small Entity: 37,697

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,182,671	1,182,671
Annual IC Time Burden (Hours)	508,549	508,549
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.