Creditable Coverage Disclosure To Cms On-line Form And Instructions : Cms-10198

CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10198 CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198 Form and Instruction
CMS-10198 Creditable Coverage Disclosure to CMS Form CMS-10198 CC Disclosure to CMS Instructions and Screen Shots 2009-07-02.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	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(e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198	Creditable Coverage Disclosure to CMS Form	CMS-10198 CC Disclosure to CMS Instructions and Screen Shots 2009-07-02.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	3	7
Annual IC Time Burden (Hours)	1	-36	37
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.