Reconsiderations & Appeals

Consumer Operated and Oriented Plan [CO-OP] Program (CMS-10392)

Documents and Forms

Document Name Document Type
Form CMS-10392 Reconsiderations & Appeals Form and Instruction
CMS-10392 CO-OP FOA CMS-10392_CO-OP_FOA_(final).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Reconsiderations & Appeals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10392	CO-OP FOA	CMS-10392_CO-OP_FOA_(final).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 103	Number of Respondents for Small Entity: 3

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Previously Approved
Annual Number of Responses for this IC	103	103
Annual IC Time Burden (Hours)	1,545	1,545
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.