Information Collection

LAN Document (CMS-10655)

IC 227625 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⚠️ Notice: This information collection may be referencing outdated material.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-10655 LAN Document (CMS-10655)	Form and Instruction
CMS-10655 GenIC#16 LAN Summit 2017 Registration Form CMS-10655 Gen IC#16 LAN Summit 2017 Registration Form.JPG	Form and Instruction
CMS-10655 Supporting Statement.docx CMS-10655 GenIC#16 Supporting Statement	IC Document

IC Title:

LAN Document (CMS-10655)

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-10655	GenIC#16 LAN Summit 2017 Registration Form	CMS-10655 Gen IC#16 LAN Summit 2017 Registration Form.JPG		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 360

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	900	900
Annual IC Time Burden (Hours)	149	149
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10655 GenIC#16 Supporting Statement	CMS-10655 Supporting Statement.docx	07/20/2017

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