Application and Eligibility Burden

Application for Coverage in the Pre-Existing Condition Insurance Plan

Documents and Forms

Document Name Document Type
Form CMS-10334 Application and Eligibility Burden Form and Instruction
CMS-10334 PCIP Application CMS-10334.Draft PCIP Application.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Application and Eligibility Burden	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-10334	PCIP Application	CMS-10334.Draft 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 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	54,500	54,500
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.