Information Collection

Monitoring and appeals process for survey vendors

IC 212011 under ICR 202005-0938-012 · OMB 0938-1249.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1249 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10520 Monitoring and appeals process for survey vendors Form and Instruction
CMS-10520 Vendor Appeal Form CMS-10520 - QHP Survey - Request for Appeal Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Monitoring and appeals process for survey vendors	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 156.1120-1125 45 CFR 156.200(b)(5) 45 CFR 156.1105 45 CFR 155.200(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10520	Vendor Appeal Form	CMS-10520 - QHP Survey - Request for Appeal Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	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: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	14	14
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.