Information Collection

Annual Report and Recordkeeping Requirements

IC 209359 under ICR 201311-0938-021 · OMB 0938-1232.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1232 can be found here:

Documents and Forms

Document Name Document Type
508_Compliant_CMS-10476_MLR_Attachment_C_MLR_Reporting_Tool_Instructions.pdf Instruction
CMS-10476 MLR Report for Contract Year 2014 508_Compliant_CMS-10476_MLR_Attachment_B_MLR_Reporting_Tool_CY2014.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Report and Recordkeeping Requirements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			508_Compliant_CMS-10476_MLR_Attachment_C_MLR_Reporting_Tool_Instructions.pdf		Yes	No	Printable Only
Form	CMS-10476	MLR Report for Contract Year 2014	508_Compliant_CMS-10476_MLR_Attachment_B_MLR_Reporting_Tool_CY2014.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 616	Number of Respondents for Small Entity: 25

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 New Statute
Annual Number of Responses for this IC	616	616
Annual IC Time Burden (Hours)	28,980	28,980
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.