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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.