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Federal forms, ICRs, and supporting documents

Information Collection

Model Creditable Coverage Disclosure Notices (CMS-10182)

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

Documents and Forms
Document Name
Document Type
Instruction
Other-Redline CC
Other-Redline Non-CC
Other-Redline Personalized
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Model Creditable Coverage Disclosure Notices (CMS-10182)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.56

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

444,613 37,697
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 1,182,671 0 0 0 0 1,182,671
Annual IC Time Burden (Hours) 508,549 0 0 0 0 508,549
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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