Incident Reporting

State Health Insurance Exchange Security Incident Report

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.