Information Collection

PCIP Authorization Form

IC 201588 under ICR 201306-0938-009 · OMB 0938-1161.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10428 PCIP Authorization Form	Form and Instruction
CMS-10428 PCIP Authorization Form CMS-10428.PCIP Authorization.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 164.508

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10428	PCIP Authorization Form	CMS-10428.PCIP Authorization.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,100	2,100
Annual IC Time Burden (Hours)	525	525
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.