Hardcopy Submission to FI or MAC

Electronic Submission of Medicare GME Affiliation Agreements

OMB: 0938-1111

IC ID: 193421

Information Collection (IC) Details

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Hardcopy Submission to FI or MAC
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 413.75 42 CFR 413.79

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10326 SAMPLE Affiliation Agreement CMS-10326 Sample_Affiliation_Agreement_(7-12-13)_508mb.docx Yes Yes Fillable Printable

Health Health Care Services

 

125 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 125 0 0 0 0 125
Annual IC Time Burden (Hours) 31 0 0 0 0 31
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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