AM and Applicable GPO (Assumptions Document)

Registration, Attestation, Assumptions Document and Data Retention Requirements for Open Payments

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1237 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10495 AM and Applicable GPO (Assumptions Document) Form and Instruction
CMS-10495 Assumptions Assumptions Submission screen shots (starting on page 6).docx Form and Instruction

Information Collection (IC) Details

IC Title:	AM and Applicable GPO (Assumptions Document)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.908(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10495	Assumptions	Assumptions Submission screen shots (starting on page 6).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,570	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,570	1,570
Annual IC Time Burden (Hours)	1,570	1,570
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.