Information Collection

Recertification request by organization

IC 216274 under ICR 201603-0938-001 · OMB 0938-1205.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1205 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10494 Recertification request by organization Form and Instruction
CMS-10494 Recertification Request Form CMS-10494 - Appendix L_Model Recertification Request Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Recertification request by organization	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.225

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	Recertification Request Form	CMS-10494 - Appendix L_Model Recertification Request Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	12,020	12,020
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.