Data Request and Attestation for PDP Sponsors

Data Request and Attestation for PDP Sponsors (CMS-10691)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.