Miscellaneous Tasks: Applicant Follows-Up, Applicant Gives Further Clarification of Data or Gives Further Application Information to CMS

PRA for the Add-On Payments for New Medical Services and Technologies Policy

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1347 can be found here:

Documents and Forms

Document Name Document Type
FY_2018_New_Technology_Cost_Spreadsheet Example.xlsx Instruction
CMS-10638 New Technology Tracking Form FY_2018_New_Technology_Tracking_Form.docx Form
CMS-10638 New Technology Application CMS-10638.PRA request FY_2019_New_Technology_Application-revised.docx Form

Information Collection (IC) Details

IC Title:	Miscellaneous Tasks: Applicant Follows-Up, Applicant Gives Further Clarification of Data or Gives Further Application Information to CMS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FY_2018_New_Technology_Cost_Spreadsheet Example.xlsx	Yes	No	Printable Only
Form	CMS-10638	New Technology Tracking Form	FY_2018_New_Technology_Tracking_Form.docx	Yes	Yes	Fillable Printable
Form	CMS-10638	New Technology Application	CMS-10638.PRA request FY_2019_New_Technology_Application-revised.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	600	600
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.