Information Collection

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

IC 189030 under ICR 200909-0938-006 · OMB 0938-1062.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10285 Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance	Form and Instruction
CMS-10285 Request for Review if you Have Been Denied Premium Assis COBRA ICR _6_8_09.doc	Form and Instruction
COBRA mkd ICR _5_29_09.doc COBRA mkd ICR _5_29_09	IC Document

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:

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	Request for Review if you Have Been Denied Premium Assistance	COBRA ICR _6_8_09.doc		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	Previously Approved
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
COBRA mkd ICR _5_29_09	COBRA mkd ICR _5_29_09.doc	09/08/2009

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