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)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.