Information Collection

SBC Disclosure

IC 199007 under ICR 201506-0938-006 · OMB 0938-1146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1146 can be found here:

2025-04-10 - No material or nonsubstantive change to a currently approved collection
2024-12-20 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
Form CMS-10407 SBC Disclosure Form and Instruction
CMS-10407 Maternity Scenario CMS-10407 - maternity_scenario.pdf Form and Instruction
CMS-10407 Diabetes Scenario CMS-10407 - diabetes_scenario.pdf Form and Instruction
CMS-10407 Diabetes Scenario Narrative CMS-10407 - diabetes_scenario_narrative.pdf Form and Instruction
CMS-10407 Uniform Glossary CMS-10407 - uniform_glossary.pdf Form
CMS-10407 Why This Matters (No Answers) CMS-10407 -instructions_why_this_matters_no_answers.pdf Form and Instruction
CMS-10407 Why This Matters (Yes Answes) CMS-10407 -instructions_why_this_matters_yes_answers.pdf Form and Instruction
CMS-10407 Group Instructions CMS-10407 - sbc_instructions_group.pdf Form and Instruction
CMS-10407 Instructions - Individual CMS-10407 - sbc_instructions_individual.pdf Form and Instruction
CMS-10407 Completed SBC First Year CMS-10407 - sample_completed_sbc_first_year.pdf Form and Instruction
CMS-10407 Completed SBC Second Year CMS-10407 - sample_completed_sbc_second_year.pdf Form and Instruction
CMS-10407 Blank SBC template second year CMS-10407 - sbc_blank_template_second_year.pdf Form and Instruction
CMS-10407 Blank SBC Template First Year CMS-10407 - sbc_template_first_year.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SBC Disclosure	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10407	Maternity Scenario	CMS-10407 - maternity_scenario.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Diabetes Scenario	CMS-10407 - diabetes_scenario.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Diabetes Scenario Narrative	CMS-10407 - diabetes_scenario_narrative.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10407	Uniform Glossary	CMS-10407 - uniform_glossary.pdf	Yes	No	Printable Only
Form and Instruction	CMS-10407	Why This Matters (No Answers)	CMS-10407 -instructions_why_this_matters_no_answers.pdf	Yes	No	Printable Only
Form and Instruction	CMS-10407	Why This Matters (Yes Answes)	CMS-10407 -instructions_why_this_matters_yes_answers.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Group Instructions	CMS-10407 - sbc_instructions_group.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Instructions - Individual	CMS-10407 - sbc_instructions_individual.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Completed SBC First Year	CMS-10407 - sample_completed_sbc_first_year.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Completed SBC Second Year	CMS-10407 - sample_completed_sbc_second_year.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Blank SBC template second year	CMS-10407 - sbc_blank_template_second_year.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Blank SBC Template First Year	CMS-10407 - sbc_template_first_year.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 408	Number of Respondents for Small Entity: 35

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 54 %

	Approved	Previously Approved
Annual Number of Responses for this IC	15,927,928	15,927,928
Annual IC Time Burden (Hours)	322,411	322,411
Annual IC Cost Burden (Dollars)	1,592,793	1,592,793

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.