HIPAA Administrative Simplification Non-Privacy Enforcement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10148 CMS-10148 - HIPAA Non-Privacy Complaint Form	Form	Removed	Available
Form CMS-10148 CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2-14-17.doc	Form	New	Available
Form CMS-10148 CMS-10148 - HIPAA Non-Privacy Complaint Form	Form	Removed	Available
Form CMS-10148 CMS-10148 - HIPAA Non-Privacy Complaint Form	Form	Removed	Available
CMS-10148_Supporting_Statement_Part_A - FINAL 2-14-17.docx	Supporting Statement A	Uploaded 2017-02-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8801	HIPAA Administrative Simplification Non-Privacy Enforcement	Form	Removed	CMS-10148 - HIPAA Non-Privacy Complaint Form
8801	HIPAA Administrative Simplification Non-Privacy Enforcement	Instruction	Removed
223444	Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	Form	New	CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2-14-17.doc
223444	Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	Instruction	New
179072	HIPAA Administrative Simplification Non-Privacy Enforcement	Form	Removed	CMS-10148 - HIPAA Non-Privacy Complaint Form
179072	HIPAA Administrative Simplification Non-Privacy Enforcement	Instruction	Removed
179071	HIPAA Administrative Simplification Non-Privacy Enforcement	Form	Removed	CMS-10148 - HIPAA Non-Privacy Complaint Form
179071	HIPAA Administrative Simplification Non-Privacy Enforcement	Instruction	Removed

ICR Details

OMB Control No: 0938-0948	ICR Reference No: 201609-0938-001
Status: Historical Active	Previous ICR Reference No: 200703-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: HIPAA Administrative Simplification Non-Privacy Enforcement
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/17/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/13/2016
Terms of Clearance: This collection has been in violation since its expiration in June 2010, a fact which shall be noted in the next Information Collection Budget.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	06/30/2010
Responses	500	0	500
Time Burden (Hours)	500	0	500
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this information collection request is to reinstate and to update the complaint form to capture complaint information voluntarily submitted to the Centers for Medicare and Medicaid Services (CMS), National Standards Group by the public regarding the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) regulations with the exception of the Privacy and Security Rules.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 1300d Name of Law: Health Insurance Portability and Accountability Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 36308	06/06/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 60704	09/02/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
HIPAA Administrative Simplification Non-Privacy Enforcement	CMS-10148	CMS-10148 - HIPAA Non-Privacy Complaint Form
HIPAA Administrative Simplification Non-Privacy Enforcement	CMS-10148	CMS-10148 - HIPAA Non-Privacy Complaint Form
HIPAA Administrative Simplification Non-Privacy Enforcement	CMS-10148	CMS-10148 - HIPAA Non-Privacy Complaint Form
Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	CMS-10148	CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2-14-17.doc

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	500	500	0	0	0	0
Annual Time Burden (Hours)	500	500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a reinstatement with change of a previously approved information collection request; however, the burden estimate remains that same at 1 hour per respondent for a total of 500 hours per year across all respondents.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/13/2016

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