Information Collection

CMS-10549.GenIC #4: MCBS Testing of Revised Advance Letter

IC 233732 under ICR 202004-0938-011 · OMB 0938-1275.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1275 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10549.GenIC#4 - Appendix A.docx	Instruction
CMS-10549.GenIC#4 - Appendix B.docx	Instruction
CMS-10549.GenIC#4 - Mini Supporting Statement.docx CMS-10549.GenIC#4 - Mini Supporting Statement	IC Document

IC Title:

CMS-10549.GenIC #4: MCBS Testing of Revised Advance Letter

Agency IC Tracking Number:

OEDA

IC Status: Unchanged

Obligation to Respond: Voluntary

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
Instruction			CMS-10549.GenIC#4 - Appendix A.docx		Yes	No	Printable Only
Instruction			CMS-10549.GenIC#4 - Appendix B.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	11,000	11,000
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10549.GenIC#4 - Mini Supporting Statement	CMS-10549.GenIC#4 - Mini Supporting Statement.docx	10/26/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.