Information Collection

Annual Report and Recordkeeping Requirements

IC 209359 under ICR 201612-0938-019 · OMB 0938-1232.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1232 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10476 MLR Report Annual Report and Recordkeeping Requirements	Form
508_CMS-10476_Attachment_C_MLR_Report_Instructions.pdf	Instruction
508_CMS-10476_Attachment_D_Crosswalk.pdf	Other-Crosswalk
CMS-10476 MLR Report 508_CMS-10476_Attachment_B_MLR_Report.pdf	Form

IC Title:

Annual Report and Recordkeeping Requirements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Form	CMS-10476	Yes	Yes	Fillable Printable
Other-Crosswalk		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 616

Number of Respondents for Small Entity: 25

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	616	616
Annual IC Time Burden (Hours)	28,980	28,980
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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