Information Collection

HIPAA Nondiscrimination Provisions (CMS-10001)

IC 8623 under ICR 200901-0938-001 · OMB 0938-0827.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

HIPAA Nondiscrimination Provisions (CMS-10001)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.121(h) 45 CFR 146.121(i)(2)(i)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	194	194
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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