OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Applicatin to Participate in the IVIG Demonstration

IC 211762 under ICR 202104-0938-011 · OMB 0938-1246.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10518
Applicatin to Participate in the IVIG Demonstration		 Form and Instruction
CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici
IVIG-Final-English-App-02.03.21.pdf 		Form and Instruction
CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici
IVIG-Final-Spanish-App-02.04.21.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Form and Instruction CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application (English) IVIG-Final-English-App-02.03.21.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application (Spanish) IVIG-Final-Spanish-App-02.04.21.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


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  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 6,500 0 0 5,280 0 1,220
Annual IC Time Burden (Hours) 1,625 0 0 1,320 0 305
Annual IC Cost Burden (Dollars) 0 0 0 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.