Information Collection

AM and Applicable GPO (Attestation)

IC 211455 under ICR 201407-0938-004 · OMB 0938-1237.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10495 AM and Applicable GPO (Attestation)	Form and Instruction
CMS-10495 Attestation Attestation Submission screen shots (starting on page 7).docx	Form and Instruction

IC Title:

AM and Applicable GPO (Attestation)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.904(b)

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-10495	Attestation	Attestation Submission screen shots (starting on page 7).docx		Yes	Yes	Fillable Fileable

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 %

table that charts list of burden
	Approved	Previously Approved
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

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.