Information Collection

Self-Certification & Notice to HHS

IC 228591 under ICR 201710-0938-006 · OMB 0938-1344.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1344 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10653 Self-Certification & Notice to HHS	Form and Instruction
CMS-10653 Certification Form CMS-10653 Certification.pdf	Form and Instruction

IC Title:

Self-Certification & Notice to HHS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(c)(3)

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 and Instruction	CMS-10653	Certification Form	CMS-10653 Certification.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	4	4
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.