State Implemented Moratorium Form

Initial Request for State Implemented Moratorium Form (CMS-10628)

OMB: 0938-1328

IC ID: 224647

Information Collection (IC) Details

View Information Collection (IC)

State Implemented Moratorium Form
 
No New
 
Required to Obtain or Retain Benefits
 
42 CFR 455.470

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10628 State Moratoria Request Form State Moratoria Request Form - revised 05042017.docx Yes Yes Fillable Fileable

Health Health Care Services

 

15 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 15 15 0 0 0 0
Annual IC Time Burden (Hours) 75 75 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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