Information Collection

Data Request and Attestation for PDP Sponsors

IC 236066 under ICR 201905-0938-006 · OMB 0938-1371.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1371 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10691 Data Request and Attestation for PDP Sponsors	Form and Instruction
CMS-10691 Data Request and Attestation Cert_Ext_MClaims_11142018.pdf	Form and Instruction

IC Title:

Data Request and Attestation for PDP Sponsors

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	CMS-10691	Data Request and Attestation	Cert_Ext_MClaims_11142018.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 68

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	73	73
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	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.