Application and Eligibility (2011)

Application for Coverage in the Pre-Existing Condition Insurance Plan

OMB: 0938-1095

IC ID: 193401

Documents and Forms
Information Collection (IC) Details

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Application and Eligibility (2011)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10334 PCIP Application CMS-10334. CLEAN - Revised PCIP Application.doc Yes No Fillable Fileable

Health Health Care Services

 

50,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 50,000 0 0 0 0 50,000
Annual IC Time Burden (Hours) 42,000 0 0 0 0 42,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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