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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.