Information Collection

Attestations

IC 229160 under ICR 201804-0938-016 · OMB 0938-1023.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1023 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10209 Attestations	Form
CMS-10209 CCIP Attestation CCIP screenshot_OMB language.pdf	Form
CMS-10209 CCIP Attestation Attachment 3_Non-Rule CCIP Attestation.docx	Form
CMS-10209 QIP Attestation Attachment 2_Non-Rule QIP Attestation.docx	Form

IC Title:

Attestations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10209	QIP Attestation	Attachment 2_Non-Rule QIP Attestation.docx	Yes	Yes	Fillable Fileable
Form	CMS-10209	CCIP Attestation	CCIP screenshot_OMB language.pdf	Yes	Yes	Fillable Printable
Form	CMS-10209	CCIP Attestation	Attachment 3_Non-Rule CCIP Attestation.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 750

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	750	750
Annual IC Time Burden (Hours)	188	188
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.