Information Collection

(149.335) - Documentation of Actual Medical Claims Involved

IC 201224 under ICR 201202-0938-004 · OMB 0938-1087.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10321 (149.335) - Documentation of Actual Medical Claims Involved	Form
ERRP Prima Facie Evidence Cover Sheet Instructions.pdf	Instruction
CMS-10321 ERRP Prima Facie Evidence Cover Sheet ERRP Prima Facie Evidence Cover Sheet.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.335

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	CMS-10321	ERRP Prima Facie Evidence Cover Sheet	ERRP Prima Facie Evidence Cover Sheet.pdf		Yes	Yes	Fillable Fileable
Instruction			ERRP Prima Facie Evidence Cover Sheet Instructions.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Early Retiree Reinsurance Program

FR Citation: 75 FR 31440

Number of Respondents: 1,420

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: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,371	2,371
Annual IC Time Burden (Hours)	208,683	208,683
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.