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Federal forms, ICRs, and supporting documents

Information Collection

Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3

IC 199556 under ICR 201202-0938-004 · OMB 0938-1087.

Documents and Forms
Document Name
Document Type
Instruction
Form
Information Collection (IC) Details

View Information Collection (IC)

Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3
 
No Removed
 
Required to Obtain or Retain Benefits
 
45 CFR 149 Subpart E

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction 0938-1087 Revised_Instrument Collection Instructions.docx Yes No Fillable Fileable
Form CMS-10321 Revised ERRP Collection Instrument 0938-1087 Revised ERRP Collection Instrument-1.docx Yes No Fillable Fileable

Health Health Care Services

 

600 0
   
Private Sector Businesses or other for-profits
 
   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 0 0 -1,200 0 0 1,200
Annual IC Time Burden (Hours) 0 0 -105,600 0 0 105,600
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.