Information Collection

Hardcopy Submission to FI or MAC

IC 193421 under ICR 201708-0938-002 · OMB 0938-1111.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1111 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10326 Hardcopy Submission to FI or MAC	Form
CMS-10326 SAMPLE Affiliation Agreement CMS-10326 Sample_Affiliation_Agreement_12012016mlnm.pdf	Form

IC Title:

Hardcopy Submission to FI or MAC

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 413.75 42 CFR 413.79

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-10326	SAMPLE Affiliation Agreement	CMS-10326 Sample_Affiliation_Agreement_12012016mlnm.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

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: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	125	125
Annual IC Time Burden (Hours)	31	31
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.