Information Collection

MA and PDP Contracts

IC 194256 under ICR 201706-0938-003 · OMB 0938-0732.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0732 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-R-246 MA and PDP Contracts Form and Instruction
CMS-R-246 MA-only Survey MA-only Survey.pdf Form and Instruction
CMS-R-246 MA-PD Survey MA-PD Survey.pdf Form and Instruction
MA-only survey crosswalk.pdf Crosswalk - MA Survey IC Document
MA-PD survey crosswalk.pdf Crosswalk - MA PD Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MA and PDP Contracts	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152 42 CFR 422.156 42 CFR 417.472

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-246	MA-only Survey	MA-only Survey.pdf		No		Fillable Printable
Form and Instruction	CMS-R-246	MA-PD Survey	MA-PD Survey.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Privacy Act of 1974: HPMS # 09-70-4004	FR Citation: 63 FR 43187

Number of Respondents: 599	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-599	599
Annual IC Time Burden (Hours)	-32,346	32,346
Annual IC Cost Burden (Dollars)	-2,995,000	2,995,000

Documents for IC

Title	Document	Date Uploaded
Crosswalk - MA Survey	MA-only survey crosswalk.pdf	06/03/2015
Crosswalk - MA PD Survey	MA-PD survey crosswalk.pdf	06/03/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.