?495.210 –Attestation on behalf of MA EPs

Electronic Health Record Incentive Program-Stage 3 (CMS-10552)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1278 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	§495.210 –Attestation on behalf of MA EPs	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 495.210

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13,635	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: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	13,635	13,635
Annual IC Time Burden (Hours)	3,409	3,409
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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No associated records found

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