Information Collection

Change of Ownership (CHOW) Purchaser Form

IC 206873 under ICR 201305-0938-005 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10169 Change of Ownership (CHOW) Purchaser Form Form and Instruction
CMS-10169 Change of Ownership (CHOW) Purchaser Form Change of Ownership Purchaser Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Change of Ownership (CHOW) Purchaser Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10169	Change of Ownership (CHOW) Purchaser Form	Change of Ownership Purchaser Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 122	Number of Respondents for Small Entity: 81

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	111	111
Annual IC Time Burden (Hours)	111	111
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.