Information Collection

Participation Agreement

IC 244606 under ICR 202007-0938-012 · OMB 0938-1388.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1388 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10728 Participation Agreement	Form and Instruction
CMS-10728 Patient Agreement ViT PA Final clean 10.15.2020.docx	Form and Instruction

IC Title:

Participation Agreement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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 and Instruction	CMS-10728	Patient Agreement	ViT PA Final clean 10.15.2020.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.