Miscellaneous Tasks: Applicant Follows-Up, Applicant Gives Further Clarification of Data or Gives Further Application Information to CMS

PRA for the Add-On Payments for New Medical Services and Technologies Policy

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1347 can be found here:

Documents and Forms

Document Name Document Type
FY_2018_New_Technology_Cost_Spreadsheet Example.xlsx Instruction
CMS-10638 New Technology Tracking Form FY_2018_New_Technology_Tracking_Form.docx Form
CMS-10638 New Technology Application CMS-10638.PRA request FY_2019_New_Technology_Application-revised.docx Form

Information Collection (IC) Details

IC Title:	Miscellaneous Tasks: Applicant Follows-Up, Applicant Gives Further Clarification of Data or Gives Further Application Information to CMS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FY_2018_New_Technology_Cost_Spreadsheet Example.xlsx	Yes	No	Printable Only
Form	CMS-10638	New Technology Tracking Form	FY_2018_New_Technology_Tracking_Form.docx	Yes	Yes	Fillable Printable
Form	CMS-10638	New Technology Application	CMS-10638.PRA request FY_2019_New_Technology_Application-revised.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 32	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	32	17	15
Annual IC Time Burden (Hours)	1,280	680	600
Annual IC Cost Burden (Dollars)	0	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.