State Implemented Moratorium Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1328 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10628 State Implemented Moratorium Form Form and Instruction
CMS-10628 State Moratoria Request Form State Moratoria Request Form - revised 05042017.docx Form and Instruction

Information Collection (IC) Details

IC Title:	State Implemented Moratorium Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 455.470

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	75	75
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.