Internet-based Self-Service Tool

Transparency in Pricing Information (CMS-10715)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.