Information Collection

155.225(b)(1) (organization follow-up for application)

IC 207873 under ICR 201703-0938-005 · OMB 0938-1205.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1205 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10494 155.225(b)(1) (organization follow-up for application) Form and Instruction
CMS-10494 CAC Organization Application CMS-10494 - Appendix A_ CAC Organization Application (1).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	155.225(b)(1) (organization follow-up for application)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.225(b)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	CAC Organization Application	CMS-10494 - Appendix A_ CAC Organization Application (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	500	500
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.