Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10198 Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf Form and Instruction
CMS-10198 CC Form (screen shot) CCUpdatedPage.docx Form

Information Collection (IC) Details

IC Title:	Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56e

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198	Creditable Coverage Disclosure to CMS	CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf		Yes	Yes	Fillable Printable
Form	CMS-10198	CC Form (screen shot)	CCUpdatedPage.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 87,128	Number of Respondents for Small Entity: 8,000

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	87,128	3,264	83,864
Annual IC Time Burden (Hours)	7,261	136	7,125
Annual IC Cost Burden (Dollars)	0	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.