Information Collection

Issuer - Attest (Small Group)

IC 199284 under ICR 201212-0938-005 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10320 Issuer - Attest (Small Group)	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 10350\10320\Files for 30-day 8-7-12\CMS-10320 Appendix_D CMS-10320 Appendix_D_BenefitsPremiumsInformation20120801.pdf	Form and Instruction

IC Title:

Issuer - Attest (Small Group)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of 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	10350\10320\Files for 30-day 8-7-12\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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	1,400	1,400
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.