Information Collection

Initial and renewal MOC Submissions

IC 218541 under ICR 201903-0938-014 · OMB 0938-1296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1296 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10565 Initial and renewal MOC Submissions	Form
CMS-10565 Model of Care Matrix Upload Document for Initial Applica Attachment A - Model of Care Matrix Upload Document for Initial Application and Renewal [rev 12-16-2015 by OSORA PRA].doc	Form
CMS-10565 Model of care matrix upload document for initial applica Attachment A_Model_of_Care_Matrix_508.pdf	Form

IC Title:

Initial and renewal MOC Submissions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10565	Model of Care Matrix Upload Document for Initial Application and Renewal	Attachment A - Model of Care Matrix Upload Document for Initial Application and Renewal [rev 12-16-2015 by OSORA PRA].doc		Yes	Yes	Fillable Printable
Form	CMS-10565	Model of care matrix upload document for initial application and renewal	Attachment A_Model_of_Care_Matrix_508.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 220

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	220	-93	313
Annual IC Time Burden (Hours)	1,320	-558	1,878
Annual IC Cost Burden (Dollars)	0	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.