Information Collection

CMS-10640 (MAC) Participant Form

IC 224394 under ICR 201509-0938-006 · OMB 0938-1297.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1297 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10640 CMS-10640 (MAC) Participant Form	Form and Instruction
CMS-10640 MAC Participant Form CMS-10640 GenIC14 Instrument - MAC Participant Form.pdf	Form and Instruction
CMS-10640 PRA Supporting Statement LAN_GenIC14 MAC Participant Form _ 10 24 2015.docx CMS-10640 Supporting Statement	IC Document

IC Title:

CMS-10640 (MAC) Participant Form

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	CMS-10640	MAC Participant Form	CMS-10640 GenIC14 Instrument - MAC Participant Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 10

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10640 Supporting Statement	CMS-10640 PRA Supporting Statement LAN_GenIC14 MAC Participant Form _ 10 24 2015.docx	11/10/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.