Appendix B

OMB Control # 0938-1284
Expiration Date: XX/XX/2023
Appendix B

PRA DISCLOSURE:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1284. The time required to complete this
information collection is estimated to average 136 hours per response for new QHP issuers and
64 hours per response for new SADP issuers in the first year, and 36 hours for returning QHP
issuers and 18 hours for returning SADP issuers in the first year. These estimates include the
time to review instructions, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send
applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control
number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact Joshua Van
Drei at [email protected].