SBC disclosure

Summary of Benefits and Coverage and Uniform Glossary

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1146 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10407 SBC disclosure Form and Instruction
Why This Matters - No Answers 2-7-12 clean.doc Instruction
Why This Matters - Yes Answers 2-7-12 clean.doc Instruction
CMS-10407 Blank SBC Template Blank SBC Template 2-7-12 clean.doc Form and Instruction
CMS-10407 Diabetes_Narrative Diabetes_Narrative_2-7-12.doc Form and Instruction
CMS-10407 Diabetes_Scenario Diabetes_Scenario_2-7-12.xlsx Form and Instruction
CMS-10407 Instructions Group Instructions Group 2-7-12 clean.docx Form and Instruction
CMS-10407 Instructions Individual Instructions Individual 2-7-12 clean.docx Form and Instruction
CMS-10407 Maternity Scenario Maternity Scenario 2-7-12.xlsx Form and Instruction
CMS-10407 Maternity_Narrative Maternity_Narrative_2-7-12.docx Form and Instruction
CMS-10407 Sample Completed SBC Sample Completed SBC 2-7-12 clean.doc Form and Instruction
CMS-10407 Uniform Glossary Uniform Glossary 2-7-12 clean.doc Form and Instruction

Information Collection (IC) Details

IC Title:	SBC disclosure	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10407	Blank SBC Template	Blank SBC Template 2-7-12 clean.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Diabetes_Narrative	Diabetes_Narrative_2-7-12.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Diabetes_Scenario	Diabetes_Scenario_2-7-12.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Instructions Group	Instructions Group 2-7-12 clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Instructions Individual	Instructions Individual 2-7-12 clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Maternity Scenario	Maternity Scenario 2-7-12.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Maternity_Narrative	Maternity_Narrative_2-7-12.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Sample Completed SBC	Sample Completed SBC 2-7-12 clean.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Uniform Glossary	Uniform Glossary 2-7-12 clean.doc	Yes	Yes	Fillable Fileable
Instruction			Why This Matters - No Answers 2-7-12 clean.doc	Yes	No	Printable Only
Instruction			Why This Matters - Yes Answers 2-7-12 clean.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 333	Number of Respondents for Small Entity: 35

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 54 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	13,000,000	13,000,000
Annual IC Time Burden (Hours)	300,000	300,000
Annual IC Cost Burden (Dollars)	1,300,000	1,300,000

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.