Information Collection

Disclosure Request Form

IC 229441 under ICR 201908-0938-016 · OMB 0938-1080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10307 Disclosure Request Form	Form and Instruction
CMS-10307 Disclosure Request Form CMS-10307 Model Form to Request MH SUD Treatment Limit Information.pdf	Form and Instruction
CMS-10307 - Model disclosure template - FINAL.docx CMS-10307 - Model Disclosure Template	IC Document

IC Title:

Disclosure Request Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 146.136(d)(2)

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-10307	Disclosure Request Form	CMS-10307 Model Form to Request MH SUD Treatment Limit Information.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 184,733

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	184,733	184,733
Annual IC Time Burden (Hours)	15,394	15,394
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10307 - Model Disclosure Template	CMS-10307 - Model disclosure template - FINAL.docx	08/30/2019

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