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)

OMB: 0938-1296

IC ID: 218541

Information Collection (IC) Details

View Information Collection (IC)

Initial and renewal MOC Submissions
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

 

220 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 220 0 -93 0 313 0
Annual IC Time Burden (Hours) 1,320 0 -558 0 1,878 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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