Information Collection

Medicare Advantage Applications - Part C (CY 2010)

IC 8785 under ICR 200906-0938-003 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10237 Medicare Advantage Applications - Part C (CY 2010)	Form and Instruction
CMS-10237 Part-C Medicare Advantage Application CMS10237-PartC-MA-APP-CLEANVERSION-12-4-08.doc	Form and Instruction
CMS-10214 Medicare Advantage/Prescription Drug Benefit CMS-10214 2009 EGWP MAO Applicationfinal1125(cleanversion).doc	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Advantage Applications - Part C (CY 2010)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.501 42 CFR 422.503 42 CFR 422.504 42 CFR 422.506 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.524 42 CFR 422.527

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-10237	Part-C Medicare Advantage Application	CMS10237-PartC-MA-APP-CLEANVERSION-12-4-08.doc		Yes	Yes	Paper Only
Form and Instruction	CMS-10214	Medicare Advantage/Prescription Drug Benefit	CMS-10214 2009 EGWP MAO Applicationfinal1125(cleanversion).doc		Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 267

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	267	267
Annual IC Time Burden (Hours)	6,490	6,490
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.