Information Collection

Portability Requirements - Individual

IC 196170 under ICR 201102-0938-007 · OMB 0938-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1100 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10339 Portability Requirements - Individual	Form and Instruction
CMS-10339 PCIP Policy Letter #3 PCIP Policy Letter No 3.pdf	Form and Instruction

IC Title:

Portability Requirements - Individual

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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-10339	PCIP Policy Letter #3	PCIP Policy Letter No 3.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	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.