Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form

HIPAA Administrative Simplification Non-Privacy Enforcement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0948 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10148 Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form Form
CMS-10148 HIPAA Non-Provacy Complaint Instructions FINAL 2-14-17.doc Instruction
CMS-10148 CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2 CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2-14-17.doc Form

Information Collection (IC) Details

IC Title:	Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	CMS-10148	CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2-14-17.doc	CMS-10148 HIPAA Non-Privacy Paper Complaint Form FINAL 2-14-17.doc		Yes	Yes	Fillable Fileable
Instruction			CMS-10148 HIPAA Non-Provacy Complaint Instructions FINAL 2-14-17.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	500	500
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.