Information Collection

Applicatin to Participate in the IVIG Demonstration

IC 211762 under ICR 201603-0938-015 · OMB 0938-1246.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1246 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10518 Applicatin to Participate in the IVIG Demonstration	Form and Instruction
CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici Revised Beneficiary Application Form English Version.pdf	Form and Instruction
CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici Revised Beneficiary Application Form Spanish Version.pdf	Form and Instruction
crosswalk - JB 03082016.doc Crosswalk	IC Document

IC Title:

Applicatin to Participate in the IVIG Demonstration

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10518	Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application	Revised Beneficiary Application Form English Version.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10518	Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application	Revised Beneficiary Application Form Spanish Version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	crosswalk - JB 03082016.doc	03/21/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.