Information Collection

Issuer - Attest (Individual)

IC 199283 under ICR 202102-0938-012 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10320 Issuer - Attest (Individual)	Form and Instruction
CMS-10320 CMS-1032 - .Issuer - FINAL Instructions and Instruments CMS 10320 Appendix G_2020 .xlsm	Form and Instruction
CMS-10320 CMS-1032 - .Issuer - FINAL Instructions and Instruments CMS 10320 Appendix G_2020 .xlsm	Form and Instruction
CMS-10320 Appendix C - Insurance Issuer and Product Level Data CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Form and Instruction
CMS-10320 Appendix C - Insurance Issuer and Product Level Data CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Form and Instruction
CMS-10320 Appendix D - Data Collection 2020 CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Form and Instruction
CMS-10320 Appendix D - Data Collection 2020 CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Form and Instruction

IC Title:

Issuer - Attest (Individual)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10320	CMS-1032 - .Issuer - FINAL Instructions and Instruments	CMS 10320 Appendix G_2020 .xlsm	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10320	Appendix C - Insurance Issuer and Product Level Data	CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10320	Appendix D - Data Collection 2020	CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 450

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	450	0	450
Annual IC Time Burden (Hours)	225	-675	900
Annual IC Cost Burden (Dollars)	0	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.