Information Collection

Application Process

IC 197223 under ICR 201104-0938-002 · OMB 0938-1131.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1131 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10382 Application Process Form and Instruction
CMS-10382 CMS-10382-APPENDIX-1-Guidelines CMS-10382-APPENDIX-1-Guidelines.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application Process	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-10382	CMS-10382-APPENDIX-1-Guidelines	CMS-10382-APPENDIX-1-Guidelines.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	2,160	2,160
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.