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Third Party Payment Notification
Third Party Payment of QHP Premiums and Additional Notices for QHP Issuers Data Collection (CMS-10595)
OMB: 0938-1301
IC ID: 219318
OMB.report
HHS/CMS
OMB 0938-1301
ICR 201512-0938-008
IC 219318
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1301 can be found here:
2023-01-23 - Extension without change of a currently approved collection
2019-09-26 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Third Party Payment Notification
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
45 CFR 156.156(f)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
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:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
500
0
0
0
0
Annual IC Time Burden (Hours)
2,000
2,000
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.