Off-cycle Submission of Summaries (MOC Changes)

Initial and Renewal Model of Care Submissions, and Off-cycle Submission of Summaries of Model of Care Changes (CMS-10565)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1296 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10565 Off-cycle Submission of Summaries (MOC Changes) Form
CMS-10565 Revised Model of Care Matrix Upload Document Attachment B - Revised Model of Care Matrix Upload Document [rev 12-16-2015 by OSORA PRA].doc Form

Information Collection (IC) Details

IC Title:	Off-cycle Submission of Summaries (MOC Changes)	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-10565	Revised Model of Care Matrix Upload Document	Attachment B - Revised Model of Care Matrix Upload Document [rev 12-16-2015 by OSORA PRA].doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 63	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	63	63
Annual IC Time Burden (Hours)	252	252
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.