Information Collection

Registry

IC 213680 under ICR 201410-0938-017 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10499 Registry	Form and Instruction
CMS-10499 Repository Email CMS-10499.Repository_Draft Email_.docx	Form and Instruction

IC Title:

Registry

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 495.6

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-10499	Repository Email	CMS-10499.Repository_Draft Email_.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	83	83
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.