Information Collection

Application and Eligibility (2012)

IC 193403 under ICR 201111-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10334 Application and Eligibility (2012)	Form and Instruction
CMS-10334 PCIP Application CMS-10334. CLEAN - Revised PCIP Application.doc	Form and Instruction

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:

table that charts list of instruments
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

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 %

table that charts list of burden
	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

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.