Information Collection

State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

IC 46153 under ICR 201604-0938-001 · OMB 0938-1013.

⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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IC Title:	State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56e

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,793	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,793	2,793
Annual IC Time Burden (Hours)	232	232
Annual IC Cost Burden (Dollars)	0	0

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