Information Collection

Incident Reporting

IC 208397 under ICR 201308-0938-026 · OMB 0938-1216.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1216 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10496 Incident Reporting	Form and Instruction
CMS-10496 STATE HEALTH INSURANCE EXCHANGE SECURITY INCIDENT REPORT CMS-10496_HIM_State_Incident_Report-508.pdf	Form and Instruction

IC Title:

Incident Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 155.260

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-10496	STATE HEALTH INSURANCE EXCHANGE SECURITY INCIDENT REPORT	CMS-10496_HIM_State_Incident_Report-508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	936	936
Annual IC Time Burden (Hours)	234	234
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.