Information Collection

Health Reimbursement Arrangements

IC 236410 under ICR 201906-0938-002 · OMB 0938-1361.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1361 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10704 Health Reimbursement Arrangements	Form and Instruction
CMS-10704 Model Notice CMS-10704.Deliberative Document.docx	Form and Instruction

IC Title:

Health Reimbursement Arrangements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 146.123(c)

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-10704	Model Notice	CMS-10704.Deliberative Document.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,005

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	272,680	272,680
Annual IC Time Burden (Hours)	6,016	6,016
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.