Issuer - Attest (Individual)

Health Care Reform Insurance Web Portal and Supporting Authority Contained in Sections 1103 and 10102 of The Patient Protection and Affordability Care Act, P.L. 111-148 (PPACA)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10320 Issuer - Attest (Individual) Form and Instruction
CMS-10320 CMS-10320.Issuer - FINAL Instructions and Instruments CMS-10320.Issuer - FINAL Instructions and Instruments (5-12-10).pdf Form and Instruction
CMS-10320 CMS-10320 Appendix_C_InsuranceIssuers CMS-10320 Appendix_C_InsuranceIssuers.pdf Form and Instruction
CMS-10320 CMS-10320 Appendix_D_BenefitsPremiumsInformation CMS-10320 Appendix_D_BenefitsPremiumsInformation20120801.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Issuer - Attest (Individual)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10320	CMS-10320.Issuer - FINAL Instructions and Instruments	CMS-10320.Issuer - FINAL Instructions and Instruments (5-12-10).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10320	CMS-10320 Appendix_C_InsuranceIssuers	CMS-10320 Appendix_C_InsuranceIssuers.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10320	CMS-10320 Appendix_D_BenefitsPremiumsInformation	CMS-10320 Appendix_D_BenefitsPremiumsInformation20120801.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	900	900
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.