Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)

OMB: 0938-1013

IC ID: 46151

Information Collection (IC) Details

View Information Collection (IC)

Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.56(e)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf Yes Yes Fillable Printable
Form CMS-10198 CC Form (screen shot) CCOnlinePageView.pdf Yes Yes Fillable Printable

Health Health Care Services

 

30 0
   
Federal Government
 
   100 %

  Requested 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 30 0 0 -57 87 0
Annual IC Time Burden (Hours) 3 0 0 -4 7 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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