AM (Attestation)

Registration, Attestation, Dispute Resolution and Correction, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495)

OMB: 0938-1237

IC ID: 211455

Information Collection (IC) Details

View Information Collection (IC)

AM (Attestation)
 
No Modified
 
Mandatory
 
42 CFR 403.904(b)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10495 Attestation CMS-10495 - Attestation and Assumptions Screen Shots 9.23.2020 - 508 cf.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

1,572 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,572 0 0 0 0 1,572
Annual IC Time Burden (Hours) 6,288 0 0 0 0 6,288
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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