Pre-site Discussions

Evaluation of Practice Models for Dual Eligibles and Medicare Beneficiaries with Serious Chronic Conditions

Documents and Forms

Document Name Document Type
Form CMS-10356 Pre-site Discussions Form and Instruction
CMS-10356 Pre-site Protocol CMS_Duals_PreSite_HRR_Protocol_PRAReview_1711(clean).doc Form and Instruction

Information Collection (IC) Details

IC Title:	Pre-site Discussions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10356	Pre-site Protocol	CMS_Duals_PreSite_HRR_Protocol_PRAReview_1711(clean).doc		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	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.