Issuer - Attest (Small Group)

Health Care Reform Insurance Web Portal Requirements 45 CFR part 159 (CMS-10320)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10320 Issuer - Attest (Small Group) Form and Instruction
CMS-10320 CMS-10320 - Issuer - FINAL Instructions and Instruments CMS 10320 Appendix G_2020 .xlsm Form and Instruction
CMS-10320 CMS-10320 - 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 CMS 10320 Appendix D_Data Collection_PRA2020.pdf Form and Instruction
CMS-10320 Appendix D - Data Collection CMS 10320 Appendix D_Data Collection_PRA2020.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Issuer - Attest (Small Group)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10320	CMS-10320 - 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	No	Fillable Fileable
Form and Instruction	CMS-10320	Appendix D - Data Collection	CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	500	-200	700
Annual IC Time Burden (Hours)	250	-1,150	1,400
Annual IC Cost Burden (Dollars)	0	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.