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De minimis for LIS individuals (CMS-10350)
De Minimis for LIS Individuals and Uniform Exceptions and Appeals Process for Prescription Drug Plans and MA-PD Plans
OMB: 0938-1338
IC ID: 195402
OMB.report
HHS/CMS
OMB 0938-1338
ICR 201011-0938-011
IC 195402
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
De minimis for LIS individuals (CMS-10350)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 423.34
42 CFR 423.780
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
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:
150
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 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
150
150
0
0
0
0
Annual IC Time Burden (Hours)
25
25
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.