Off-cycle Submission of Summaries (MOC Changes)

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: 218542

Information Collection (IC) Details

View Information Collection (IC)

Off-cycle Submission of Summaries (MOC Changes)
 
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 Revised Model of Care Matrix Upload Document Attachment B - Revised Model of Care Matrix Upload Document [rev 12-16-2015 by OSORA PRA].doc Yes Yes Fillable Printable
Form CMS-10565 Revised Model of Care Matrix Upload Document Attachment B - Model of Care Matrix Upload Document Off-Clycle Submissio.._.pdf Yes Yes Fillable Printable

Health Health Care Services

 

103 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 103 0 40 0 63 0
Annual IC Time Burden (Hours) 412 0 160 0 252 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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