Information Collection

Internet-based Self-Service Tool

IC 238757 under ICR 201912-0938-001 · OMB 0938-1372.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1372 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10715 - Appendix 2 - Negotiated Rate Data File.pdf	Other-Guidance
CMS-10715 Appedndix 3 - Allowed Amounts Data File.pdf	Other-Guidance

IC Title:

Internet-based Self-Service Tool

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 47 CFR 147.210(b)(2)(i)

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
Other-Guidance			CMS-10715 - Appendix 2 - Negotiated Rate Data File.pdf		Yes	Yes	Fillable Fileable
Other-Guidance			CMS-10715 Appedndix 3 - Allowed Amounts Data File.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 980

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
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	980	980
Annual IC Time Burden (Hours)	913,547	913,547
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.