Participation Agreement

Value in Opioid Use Disorder Treatment Demonstration (CMS-10728)

OMB: 0938-1388

IC ID: 244606

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Participation Agreement
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10728 Patient Agreement ViT PA Final clean 10.15.2020.docx Yes Yes Fillable Printable

Health Health Care Services

 

100 0
   
Individuals or Households
 
   100 %

  Approved 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 100 100 0 0 0 0
Annual IC Time Burden (Hours) 200 200 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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