Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form

HIPAA Administrative Simplification Non-Privacy Enforcement

OMB: 0938-0948

IC ID: 223444

Information Collection (IC) Details

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Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10148 HIPAA Administrative Simplification (Non-Privacy) Complaint Form CMS-10148. HIPAA Administrative Simplification (Non-Privacy) Complaint Form - final.pdf Yes Yes Fillable Fileable

Health Health Care Services

Program Information Management System (PIMS)  75 FR 18841

125 0
   
Individuals or Households
 
   80 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 125 0 0 -375 0 500
Annual IC Time Burden (Hours) 125 0 0 -375 0 500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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