Monthly Data Submission Accuracy Certification Form

Payment Collections Operations Contingency Plan

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.