Information Collection

Change of Ownership (CHOW) Forms-60-day & 30-day notices

IC 206872 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⚠️ Notice: This information collection may be referencing outdated material.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 Change of Ownership (CHOW) Forms-60-day & 30-day notices	Form and Instruction
CMS-10169 CHOW 60-day Notice(Change of Ownership Form) CHOW 60 Day 508.pdf	Form and Instruction
CMS-10169 CHOW 30-day Notice(Change of Ownership Form) CHOW 30 Day 508.pdf	Form and Instruction

IC Title:

Change of Ownership (CHOW) Forms-60-day & 30-day notices

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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	CHOW 30-day Notice(Change of Ownership Form)	CHOW 30 Day 508.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10169	CHOW 60-day Notice(Change of Ownership Form)	CHOW 60 Day 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: 92

Number of Respondents for Small Entity: 64

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	92	0	92
Annual IC Time Burden (Hours)	169	123	46
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.