Information Collection

Indirect Medical Education (IME) and Supporting Regulations 42 CFR 412.105

IC 8078 under ICR 201001-0938-010 · OMB 0938-0456.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0456 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-R-64.Attachment1 - Instructions.doc	Instruction
CMS-R-64.Attachment2.doc	Instruction

IC Title:

Indirect Medical Education (IME) and Supporting Regulations 42 CFR 412.105

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 412.105

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
Instruction			CMS-R-64.Attachment1 - Instructions.doc		Yes	Yes	Fillable Fileable
Instruction			CMS-R-64.Attachment2.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,190

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Farms

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	1,190	-25	1,215
Annual IC Time Burden (Hours)	2,380	-50	2,430
Annual IC Cost Burden (Dollars)	0	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.