Information Collection

IDEAS forms

IC 219315 under ICR 201512-0938-007 · OMB 0938-1305.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS10583 IDEAS forms	Form and Instruction
CMS10583 IDEAS Assessment IDEAS Assessment Form 508.pdf	Form and Instruction
CMS-10583 IDEAS Eligibility Form IDEAS Eligibility Form 508.pdf	Form and Instruction
CMS-10583 IDEAS Post - PET form IDEAS Post-PET Form 508.pdf	Form and Instruction
CMS-10583 IDEAS Pre-PET form IDEAS Pre-PET Form 508.pdf	Form and Instruction

IC Title:

IDEAS forms

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS10583	IDEAS Assessment	IDEAS Assessment Form 508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10583	IDEAS Eligibility Form	IDEAS Eligibility Form 508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10583	IDEAS Post - PET form	IDEAS Post-PET Form 508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10583	IDEAS Pre-PET form	IDEAS Pre-PET Form 508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Data Collection Secondary to Coverage Decision System

FR Citation: 70 FR 53667

Number of Respondents: 3,700

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	3,700	3,700
Annual IC Time Burden (Hours)	6,475	6,475
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.