Information Collection

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

IC 184936 under ICR 200805-0938-006 · OMB 0938-1048.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-Survey, Form and Letters					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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Cross-walk document and Track Changes		04/29/2008

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

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