Information Collection

AM (Data Collection and Submission)

IC 230225 under ICR 201911-0938-008 · OMB 0938-1237.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1237 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10495 AM (Data Collection and Submission)	Form and Instruction
CMS-10495 Open Payments User Guide CMS-10495 - Open-Payments-User-Guide 2018.pdf	Form and Instruction
CMS-10495 General-Research-Ownership Submission Data Elements and CMS-10495 - General-Research-Ownership Submission Data Elements and Screen Shots.pdf	Form and Instruction
CMS-10495 Change Summary 2019.xlsx Crosswalk	IC Document

IC Title:

AM (Data Collection and Submission)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.908

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-10495	Open Payments User Guide	CMS-10495 - Open-Payments-User-Guide 2018.pdf		Yes	Yes	Paper Only
Form and Instruction	CMS-10495	General-Research-Ownership Submission Data Elements and Screen Shots	CMS-10495 - General-Research-Ownership Submission Data Elements and Screen Shots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,572

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,572	-23	1,595
Annual IC Time Burden (Hours)	1,639,612	1,602,337	37,275
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-10495 Change Summary 2019.xlsx	01/31/2020

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