Evaluation of Care and Disease Management Under Medicare Advantage (CMS-10255)

Evaluation of Care and Disease Management Under Medicare Advantage

Documents and Forms

Document Name Document Type
Revised Collection Instruments.doc Other-Survey, Form and Letters
Cross-walk document and Track Changes.doc Cross-walk document and Track Changes IC Document

Information Collection (IC) Details

IC Title:	Evaluation of Care and Disease Management Under Medicare Advantage (CMS-10255)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey, Form and Letters			Revised Collection Instruments.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 475	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: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	475	475
Annual IC Time Burden (Hours)	435	435
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Cross-walk document and Track Changes	Cross-walk document and Track Changes.doc	04/29/2008

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