Information Collection

Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)

IC 8785 under ICR 201111-0938-003 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10237 Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Form and Instruction
2013_HSD_Instructions_2013.pdf	Instruction
CMS-10237 2013_HSD_Exception_Request_Template 2013_HSD_Exception_Request_Template (REVISED).pdf	Form and Instruction
CMS-10237 CMS-10237_MA_Facility_Table_2013 CMS-10237_MA_Facility_Table_2013.pdf	Form
CMS-10237 CMS-10237_MA_Provider_Table_2013. CMS-10237_MA_Provider_Table_2013.pdf	Form
CMS-10237 CMS-10237 Part C MA and Cost Plan Applications CMS-10237.PartC MA and Cost Plan Applications- Clean-final 12-13-1.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.503 42 CFR 422.504 42 CFR 422.506 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.524 42 CFR 422.527 42 CFR 417.400 42 CFR 422.501

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10237	2013_HSD_Exception_Request_Template	2013_HSD_Exception_Request_Template (REVISED).pdf	Yes	Yes	Fillable Fileable
Instruction			2013_HSD_Instructions_2013.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10237	CMS-10237_MA_Facility_Table_2013	CMS-10237_MA_Facility_Table_2013.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10237	CMS-10237_MA_Provider_Table_2013.	CMS-10237_MA_Provider_Table_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10237	CMS-10237 Part C MA and Cost Plan Applications	CMS-10237.PartC MA and Cost Plan Applications- Clean-final 12-13-1.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 378

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	378	-492	870
Annual IC Time Burden (Hours)	13,296	-2,400	15,696
Annual IC Cost Burden (Dollars)	0	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.