Applicatin to Participate in the IVIG Demonstration

Application for Participation in the Intravenous Immune Globulin (IVIG) Demonstration (CMS-10518)

Documents and Forms

Document Name Document 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

IC Title:	Applicatin to Participate in the IVIG Demonstration	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:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,500	5,280	1,220
Annual IC Time Burden (Hours)	1,625	1,320	305
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.