Information Collection

Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A)

IC 8808 under ICR 201307-0938-008 · OMB 0938-0952.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10130 Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A)	Form and Instruction
CMS-10130 SECTION 1011 PROVIDER PAYMENT DETERMINATION CMS-10130A.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10130	SECTION 1011 PROVIDER PAYMENT DETERMINATION	CMS-10130A.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	300,000	300,000
Annual IC Time Burden (Hours)	74,970	74,970
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.