Letter of Intent and Submission of Contact Information

Temporary High Risk Pool Program (CMS-10319)

Documents and Forms

Document Name Document Type
Form CMS-10319 Letter of Intent and Submission of Contact Information Form and Instruction
CMS-10319 Appendix A High Risk Pools.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Letter of Intent and Submission of Contact Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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-10319	Appendix A	High Risk Pools.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2	0	-49	51
Annual IC Time Burden (Hours)	8	8	0	0
Annual IC Cost Burden (Dollars)	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.