Data Elements for General Function of an Exchange

Information Collection Requirements for Non-Exchange Entities (CMS-10633)

Documents and Forms

Document Name Document Type
Form CMS-10633 Data Elements for General Function of an Exchange Form and Instruction
CMS-10633 Appendix A - Agents and Brokers Appendix A - Agents and Brokers 92916.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Data Elements for General Function of an Exchange	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10633	Appendix A - Agents and Brokers	Appendix A - Agents and Brokers 92916.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 104,325	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	104,325	104,325
Annual IC Time Burden (Hours)	506,734	506,734
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.