Information Collection

Essential Community Provider Petition

IC 218061 under ICR 201508-0938-015 · OMB 0938-1295.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1295 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMs-10561 Essential Community Provider Petition	Form
CMs-10561 ECP Provider Petition CMS-10561 - ECP_Provider_Petition_v2.7_08-14-15.xlsm	Form
CMS-10561 ECP Provider Petition Instructions CMS-10561 - ECP Provider Petition Instructions Rev120215.docx	Form and Instruction

IC Title:

Essential Community Provider Petition

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	CMs-10561	ECP Provider Petition	CMS-10561 - ECP_Provider_Petition_v2.7_08-14-15.xlsm		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10561	ECP Provider Petition Instructions	CMS-10561 - ECP Provider Petition Instructions Rev120215.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31,634

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	31,634	31,634
Annual IC Time Burden (Hours)	53,491	53,491
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.