Application and Eligibility (2010)

Application for Coverage in the Pre-Existing Condition Insurance Plan

OMB: 0938-1095

IC ID: 193399

Information Collection (IC) Details

View Information Collection (IC)

Application and Eligibility (2010)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) PreExistingCondition_EnrollmentForm_November_2010_English_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version) PreExistingConditionPlan_ November_2010_Spanish_508.pdf Yes No Fillable Fileable

Health Health Care Services

 

100,000 0
   
Individuals or Households
 
   0 %

  Approved 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 100,000 0 0 0 0 100,000
Annual IC Time Burden (Hours) 84,000 0 0 0 0 84,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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