Information Collection

Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348

IC 8133 under ICR 201910-0938-006 · OMB 0938-0512.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0512 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-576A Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348	Form and Instruction
CMS-576A Health Insurance Benefits Agreement CMS-576A Form.pdf	Form and Instruction

IC Title:

Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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-576A	Health Insurance Benefits Agreement	CMS-576A Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Orgran Procurement Organization System (OPOS)

FR Citation: 71 FR 29336

Number of Respondents: 58

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	58	0	58
Annual IC Time Burden (Hours)	29	-87	116
Annual IC Cost Burden (Dollars)	0	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.