Information Collection

DDR Product Data (CMS-367c)

IC 222506 under ICR 202102-0938-016 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-367c - Screenshots of MDP Web-Based Instructions_07.2021_508.pdf	Instruction
CMS-367c - Screenshots of MDP Web-Based Instructions_07.2021_508.pdf	Instruction
CMS-367c Product Data CMS-367c - Screenshots of MDP Online Data Entry_07.2021_508.pdf	Form
CMS-367c Product Data CMS-367c - Screenshots of MDP Online Data Entry_07.2021_508.pdf	Form
CMS Form-367c_Product Data_Crosswalk_07.2021_508.pdf CMS-367c - Crosswalk	IC Document
CMS Form-367c_Product Data_Crosswalk_07.2021_508.pdf CMS-367c - Crosswalk	IC Document

IC Title:

DDR Product Data (CMS-367c)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			CMS-367c - Screenshots of MDP Web-Based Instructions_07.2021_508.pdf		Yes	Yes	Fillable Fileable
Form	CMS-367c	Product Data	CMS-367c - Screenshots of MDP Online Data Entry_07.2021_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 749

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
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	749	6	743
Annual IC Time Burden (Hours)	32,582	261	32,321
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-367c - Crosswalk	CMS Form-367c_Product Data_Crosswalk_07.2021_508.pdf	02/26/2021

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