Information Collection

Monitoring and appeals process for survey vendors

IC 212011 under ICR 201409-0938-003 · OMB 0938-1249.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1249 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10520 Monitoring and appeals process for survey vendors	Form and Instruction
CMS-10520 Vendor Appeal Form CMS-10520 - Vendor Appeal Form_508.pdf	Form and Instruction

IC Title:

Monitoring and appeals process for survey vendors

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 155.200(d) 45 CFR 156.1105 45 CFR 156.1120-1125 45 CFR 156.200(b)(5)

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-10520	Vendor Appeal Form	CMS-10520 - Vendor Appeal Form_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	45	45
Annual IC Time Burden (Hours)	45	45
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.