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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10115 FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115)	Form and Instruction
CMS-10115 Section 1011 Provider Enrollment Application CMS-10115 - CLEAN.docx	Form and Instruction
JUSTIFICATION_for_REQUESTING_SOC_SEC_NOS_MED_JA 03212013.doc JUSTIFICATION_for_REQUESTING_SOC_SEC_NOS_MED_JA 03212013	IC Document
Crosswalk_JA 03212013.doc Crosswalk_JA 03212013	IC Document

IC Title:

FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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-10115	Section 1011 Provider Enrollment Application	CMS-10115 - CLEAN.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

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: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	4,998	4,998
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.