Cms-1500(08-05)

Centers for Medicare & Medicaid Services

Office of Strategic Operations and Regulatory Affairs

Paperwork Reduction Act (PRA)

RECORD OF INFORMATION COLLECTION CLEARANCES

Center/Office: OIS	Type: New Revision Reinstatement Extension Emergency Discontinuation
Center/Office POC: Brian Reitz
Division Director: Chris Stahlecker	Due to OSORA/PRA:	Date submitted to OSORA/PRA:
CMS Form/Collection: CMS-1500 (08-05)	Target 60-day FR Pub. Date:	Target 30-day FR Pub. Date:
OMB Control #: 0938-New	Target Date for OMB Clearance:
Collection Title: Health Insurance Common Claim Form

RECORD OF OFFICE /CENTER CLEARANCES

Sent To:	Contact Name:	Response:	Clearance Due:	Clearance Rec’d:
CCIIO
CM/CMM
CM/CPC
CMCS
CMMI
CPI
CSP/ORDI
FCHC
OACT
OBIS/OEA
OCSQ
OESS
OFM
OGC
OIS	Brian Reitz
OL
OOM

Options: C=concur, CWC=concur with comments, NC=nonconcur, NC=no comment.

Section 508 Compliance Signature: _____________________________ ____/____/____

Printed: _____________________________

Center/Office Director Signature: _____________________________ ____/____/____

Printed _____________________________

Center/Office Director Signature: Signature required for all “New,” “Revision, ”Reinstatement”, “Emergency” and “Discontinuation” Collections. Collections seeking Extensions may be signed by a Group Director.

TO BE COMPLETED BY OSORA:

Approved By: 60-day FR notice (Draft package = Component Supervisor signature needed)

30-day FR notice (Final package = Component Supervisor initials needed)

Emergency FR notice (Component Supervisor Signature needed)

60-day/Emergency FR notices 30-day FR notices

(Signature /Date) (Initials/Date)

PRA Analyst: ______________________________ ____/____/____ ______/______

RDG Division Director: ______________________________ ____/____/____ ______/______

RDG PRA Lead ______________________________ ____/____/____ ______/______

RDG Director: ______________________________ ____/____/____ ______/______