Information Collection

IDEAS forms

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.