Prepaid Health Plan Cost Report (HMO)

Prepaid Health Plan Cost Report

OMB: 0938-0165

IC ID: 190488

Information Collection (IC) Details

View Information Collection (IC)

Prepaid Health Plan Cost Report (HMO)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 417.572 42 CFR 417.576

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-276 Final Cost Report FinalCostReport-Revised vj508.pdf Yes Yes Fillable Fileable
Form CMS-276 4th Quarter Cost Report CMS-276.4th Quarter Report.xls Yes Yes Fillable Fileable
Instruction CostReportInstructionsFinal vj 508.pdf Yes No Fillable Printable
Form CMS-276 Interim Report interim(1) vj508.pdf Yes Yes Fillable Printable
Form CMS-276 Budget Forecast Budget-Revised vj508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

19 0
   
Private Sector Businesses or other for-profits
 
   85 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 76 0 0 -16 92 0
Annual IC Time Burden (Hours) 3,572 0 0 -752 4,324 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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