Information Collection

ESRD System Access Request Form

IC 209155 under ICR 201310-0938-015 · OMB 0938-1234.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.