Information Collection

Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance

IC 189030 under ICR 200905-0938-001 · OMB 0938-1062.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1062 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10285 Request for Expedited Review of Denial of Premium Assistance Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance	Form and Instruction
CMS-10285 Request for Expedited Review of Denial of Premium Assist COBRA_Req_Rev_5_20_09_CPC .doc	Form and Instruction

IC Title:

Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form and Instruction	CMS-10285				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	12,000	12,000
Annual IC Cost Burden (Dollars)	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.

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