Initial and renewal MOC Submissions

Initial and Renewal Model of Care Submissions, and Off-cycle Submission of Summaries of Model of Care Changes (CMS-10565)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.