Information Collection

Model Creditable Coverage Disclosure Notices (CMS-10182)

IC 8852 under ICR 200810-0938-015 · OMB 0938-0990.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10182 NC-SP Model Creditable Coverage Disclosure Notices (CMS-10182)	Form and Instruction
PRA CC disclosure TRK- Updated 03.13.08 for 02 01 09.doc	Other-10182 CC-Track change
PRA Non-CC disclosure TRK - Updated 04.23.08 for 02 01 09.doc	Other-CMS 10182 NC-Track Changes
CC Guidance - Fed PRA - Updated 06 06 08 for 02 01 09.(2).doc	Other-CC Guidance
CC Guidance - Fed PRA TRK - Updated 04.23.08 for 02 01 09.(2).doc	Other-CC Guidance Track Changes
CMS-10182 NC-SP Aviso Importante de [Inserte el Nombre de la Entidad] So CMS_10182NC_Spanish_7_31_08.doc	Form and Instruction
CMS-10182 CC-SP Aviso Importante de [Inserte el Nombre de la Entidad] So CMS_10182CC_Spanish_7_31_08.doc	Form and Instruction
CMS-10182 NC Important Notice from [Insert Name of Entity] About PRA CC disclosure - Updated 06.06.08 for 02 01 09.doc	Form and Instruction
CMS-10182 NC Important Notice From [Insert Name of Entity] About PRA Non-CC disclosure - Updated 06.06.08 for 02 01 09.(2).doc	Form and Instruction

IC Title:

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(c)&(d)

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
Form and Instruction	CMS-10182 NC-SP	Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare	CMS_10182NC_Spanish_7_31_08.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10182 CC-SP	Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare	CMS_10182CC_Spanish_7_31_08.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10182 NC	Important Notice from [Insert Name of Entity] About	PRA CC disclosure - Updated 06.06.08 for 02 01 09.doc	Yes	Yes	Paper Only
Other-10182 CC-Track change			PRA CC disclosure TRK- Updated 03.13.08 for 02 01 09.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10182 NC	Important Notice From [Insert Name of Entity] About	PRA Non-CC disclosure - Updated 06.06.08 for 02 01 09.(2).doc	Yes	Yes	Paper Only
Other-CMS 10182 NC-Track Changes			PRA Non-CC disclosure TRK - Updated 04.23.08 for 02 01 09.doc	Yes	Yes	Paper Only
Other-CC Guidance			CC Guidance - Fed PRA - Updated 06 06 08 for 02 01 09.(2).doc	Yes	Yes	Paper Only
Other-CC Guidance Track Changes			CC Guidance - Fed PRA TRK - Updated 04.23.08 for 02 01 09.(2).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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,186,268	3,597	1,182,671
Annual IC Time Burden (Hours)	513,772	5,223	508,549
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.