Information Collection

Monthly Data Submission Accuracy Certification Form

IC 209729 under ICR 201312-0938-011 · OMB 0938-1217.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1217 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10515 Monthly Data Submission Accuracy Certification Form	Form and Instruction
CMS-10515 Enrollment and Payment Data Template Submission Accuracy Payment Data Submission Certification (2).docx	Form and Instruction

IC Title:

Monthly Data Submission Accuracy Certification Form

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:

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-10515	Enrollment and Payment Data Template Submission Accuracy Certification Form	Payment Data Submission Certification (2).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 575

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 New Statute
Annual Number of Responses for this IC	3,450	3,450
Annual IC Time Burden (Hours)	575	575
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.