Essential Community Provider Petition

Essential Community Provider Data Collection to Support QHP Certification for PY 2017 (CMS-10561)

OMB: 0938-1295

IC ID: 218061

Information Collection (IC) Details

View Information Collection (IC)

Essential Community Provider Petition
No Modified
Required to Obtain or Retain Benefits

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMs-10561 ECP Provider Petition CMS-10561 - ECP_Provider_Petition_v2.7_08-14-15.xlsm Yes Yes Fillable Fileable
Form and Instruction CMS-10561 ECP Provider Petition Instructions CMS-10561 - ECP Petition PRA Supporting Statement 2018-19.pdf Yes No Fillable Fileable

Health Public Health Monitoring


14,958 0
Private Sector Businesses or other for-profits, Not-for-profit institutions
   0 %

  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 14,958 0 0 -16,676 0 31,634
Annual IC Time Burden (Hours) 22,404 0 0 -31,087 0 53,491
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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