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Federal forms, ICRs, and supporting documents

Information Collection

Federal Reimbursement Of Emergency Health Services Furnished To Undocumented Aliens (section 1011) Provider Enrollment Application (cms-10115)

IC 37924 under ICR 201307-0938-009 · OMB 0938-0929.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10115 Section 1011 Provider Enrollment Application CMS-10115 - CLEAN.docx Yes No Fillable Printable

Health Health Care Services

 

10,000 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  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 10,000 0 0 0 10,000 0
Annual IC Time Burden (Hours) 4,998 0 0 0 4,998 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
JUSTIFICATION_for_REQUESTING_SOC_SEC_NOS_MED_JA 03212013 JUSTIFICATION_for_REQUESTING_SOC_SEC_NOS_MED_JA 03212013.doc 07/18/2013
Crosswalk_JA 03212013 Crosswalk_JA 03212013.doc 07/18/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.