ESRD System Access Request Form

End Stage Renal Disease (ESRD) System Access Request Form

Documents and Forms

Document Name Document Type
Form CMS-10484 ESRD System Access Request Form Form and Instruction
CMS-10484 ESRD System Access Request Form ESRD_Application_Access_Form_FINAL_14Jan2013.pdf Form and Instruction
Crosswalk.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	ESRD System Access Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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-10484	ESRD System Access Request Form	ESRD_Application_Access_Form_FINAL_14Jan2013.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27,000	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27,000	27,000
Annual IC Time Burden (Hours)	6,750	6,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk.docx	10/31/2013

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