Information Collection

Application and Eligibility (2012)

IC 193403 under ICR 201104-0938-001 · OMB 0938-1095.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1095 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10334 Application and Eligibility (2012) Form and Instruction
CMS-10334 PreExistingConditionPlan_EnrollmentForm_Spanish_508 PreExistingConditionPlan_EnrollmentForm_Spanish_508.pdf Form and Instruction
CMS-10334 CMS-10334.DRAFT Federal fallback enrollment form CMS-10334.DRAFT Federal fallback enrollment form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application and Eligibility (2012)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-10334	PreExistingConditionPlan_EnrollmentForm_Spanish_508	PreExistingConditionPlan_EnrollmentForm_Spanish_508.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10334	CMS-10334.DRAFT Federal fallback enrollment form	CMS-10334.DRAFT Federal fallback enrollment form.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	42,000	42,000
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.