OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

SBC Disclosure

IC 199007 under ICR 201908-0938-004 · OMB 0938-1146.

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Coverage Calculator
Form and Instruction
Form and Instruction
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

SBC Disclosure
 
No Modified
 
Mandatory
 
45 CFR 147.200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10407 Diabetes Narrative CMS-10407 - Diabetes Narrative-.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10407 Maternity Scenario CMS-10407 - Maternity-Care-Narrative-.pdf Yes Yes Fillable Fileable
Form CMS-10407 Uniform Glossary CMS-10407 - Uniform Glossary-.pdf Yes No Printable Only
Form and Instruction CMS-10407 What the plan covers and What you pay (No Answers) CMS-10407 - Why_this_Matters_for_SBC_No_Answers-.pdf Yes No Printable Only
Form and Instruction CMS-10407 What the plan covers and what you play (Yes Answes) CMS-10407 - Why_this_Matters_for_SBC_Yes_Answers_English -.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Group Instructions CMS-10407 - Group_Instructions_Updated-.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Instructions - Individual CMS-10407 - Individual_Instructions_Updated-.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Completed SBC Sample CMS-10407 - SBC Completed -.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Blank Template CMS-10407 - SBC_Template-.pdf Yes Yes Printable Only
Form CMS-10407 Coverage Examples - Narrative Foot Fracture CMS-10407 - Foot-Fracture-Narrative-.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Coverage Calculator Instructions CMS-10407 - Coverage-Examples-Calculator-Instructions-.pdf Yes Yes Printable Only
Other-Coverage Calculator CMS-10406 - Coverage Examples Calculator.xlsm Yes No Fillable Fileable
Form and Instruction CMS-10407 Having a baby CMS-10407 - Having a Baby -.pdf Yes No Fillable Fileable
Form and Instruction CMS-10407 Managing diabetes CMS-10407 - Managing-Type-2-Diabetes-Guide-.pdf Yes No Paper Only
Form CMS-10407 SBC Glossary Anchor CMS-10407 - List of Anchors -.xlsx Yes No Paper Only
Form and Instruction CMS-10407 Simple Fracture Simple-Fracture-Guide_508.pdf Yes No Paper Only

Health Health Care Services

 

128,511 35
   
Private Sector Businesses or other for-profits
 
   70 %

  Requested 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 24,417,090 0 0 -16,747,673 41,164,763 0
Annual IC Time Burden (Hours) 214,791 0 0 -110,062 324,853 0
Annual IC Cost Burden (Dollars) 4,553,787 0 0 437,311 4,116,476 0

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.