Information Collection

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

IC 46152 under ICR 200911-0938-003 · OMB 0938-1013.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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 423.56e

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-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: 86,560

Number of Respondents for Small Entity: 8,000

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	86,560	-358,459	445,019
Annual IC Time Burden (Hours)	7,213	-28,389	35,602
Annual IC Cost Burden (Dollars)	0	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.