Information Collection

Initial and renewal MOC Submissions

IC 218541 under ICR 202001-0938-008 · OMB 0938-1296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1296 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10565 Initial and renewal MOC Submissions	Form
CMS-10565 Model of Care Matrix Upload Document for Initial Applica Attachment A_Model_of_Care_Matrix_Initial Application and Renewal.pdf	Form
Crosswalk Attachment A CMS 10565 OMB 0938-1296.pdf Crosswalk	IC Document

IC Title:

Initial and renewal MOC Submissions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 273

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: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	287	67	220
Annual IC Time Burden (Hours)	1,680	360	1,320
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.