Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10198 Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf Form and Instruction
Crosswalk.xlsx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56(e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198	Creditable Coverage Disclosure to CMS	CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 87	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	87	87
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk.xlsx	04/04/2016

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