Individual Screener

Consumer Research Supporting Outreach for Health Insurance Marketplace

Documents and Forms

Document Name Document Type
Form CMS-10458 Individual Screener Form and Instruction
CMS-10458 Individual Screener CMS-10458_Individual_Marketplace_Screener_(REVISED).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Individual Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10458	Individual Screener	CMS-10458_Individual_Marketplace_Screener_(REVISED).pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	940	940
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.