Quarterly and Monthly Reporting

Pre-Existing Condition Insurance Plan and Supporting Regulations

Documents and Forms

Document Name Document Type
Form CMS-10339 Quarterly and Monthly Reporting Form and Instruction
CMS-10339 State Solicitation CMS-10339.state_solicitation.pdf Form and Instruction
CMS-10339 Contract Template CMS-10339.HHS Template Contract.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Quarterly and Monthly Reporting	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10339	State Solicitation	CMS-10339.state_solicitation.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10339	Contract Template	CMS-10339.HHS Template Contract.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	14,688	14,688
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.