Information Collection

Subcontracting Disclosure

IC 203541 under ICR 201701-0938-004 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10169 Subcontracting Disclosure	Form and Instruction
CMS-10169 Subcontracting Disclosure Subcontractor Disclosure Form 508.pdf	Form and Instruction

IC Title:

Subcontracting Disclosure

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.422(f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10169	Subcontracting Disclosure	Subcontractor Disclosure Form 508.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 516

Number of Respondents for Small Entity: 372

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	516	126	390
Annual IC Time Burden (Hours)	165	5	160
Annual IC Cost Burden (Dollars)	0	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.