Initial and renewal MOC Submissions

Initial and Renewal Model of Care Submissions, and Off-cycle Submission of Summaries of Model of Care Changes (CMS-10565)

OMB: 0938-1296

IC ID: 218541

Information Collection (IC) Details

View Information Collection (IC)

Initial and renewal MOC Submissions
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10565 Model of Care Matrix Upload Document for Initial Application and Renewal Attachment A_Model_of_Care_Matrix_Initial Application and Renewal.pdf Yes Yes Fillable Printable

Health Health Care Services

 

273 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 287 67 0 0 0 220
Annual IC Time Burden (Hours) 1,680 360 0 0 0 1,320
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Crosswalk Attachment A CMS 10565 OMB 0938-1296.pdf 03/06/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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