Reapplication Submission Requirement for Qualified Entities under ACA Section 10332

Reapplication Submission Requirement for Qualified Entities under ACA Section 10332 (CMS-10596)

Documents and Forms

Document Name Document Type
Form CMS-10596 Reapplication Submission Requirement for Qualified Entities under ACA Section 10332 Form and Instruction
CMS-10596 QE Reapplication Form CMS-10596_QE_Reapplication Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Reapplication Submission Requirement for Qualified Entities under ACA Section 10332	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 401.709

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10596	QE Reapplication Form	CMS-10596_QE_Reapplication Form.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	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	10	10
Annual IC Time Burden (Hours)	1,200	1,200
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.