Information Collection

AM and Applicable GPO (Data submission)

IC 230225 under ICR 201707-0938-018 · OMB 0938-1237.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1237 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10495 AM and Applicable GPO (Data submission)	Form
CMS-10495 Open Payments User Guide - Data Submission CMS-10495 - Open-Payments-User-Guide 2018.pdf	Form

IC Title:

AM and Applicable GPO (Data submission)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.908

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	CMS-10495	Open Payments User Guide - Data Submission	CMS-10495 - Open-Payments-User-Guide 2018.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,595

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,595	1,595
Annual IC Time Burden (Hours)	37,275	37,275
Annual IC Cost Burden (Dollars)	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.