Information Collection

Paper Disclosure

IC 238758 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
CMS-10715 - Appendix 1 - Model Notice.pdf Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Paper Disclosure	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.210(b)(2)(ii)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10715 - Appendix 1 - Model Notice.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 653	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 54 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	35,262	35,262
Annual IC Time Burden (Hours)	9,675	9,675
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.