Information Collection

Hardcopy Submission to FI or MAC

IC 193421 under ICR 202104-0938-014 · OMB 0938-1111.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1111 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10326 Hardcopy Submission to FI or MAC Form
CMS-10326 SAMPLE Affiliation Agreement CMS-10326 Sample_Affiliation_Agreement_01-29-21.pdf Form
CMS-10326 SAMPLE Affiliation Agreement CMS-10326 Sample_Affiliation_Agreement_01-29-21.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hardcopy Submission to FI or MAC	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.75 42 CFR 413.79

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10326	SAMPLE Affiliation Agreement	CMS-10326 Sample_Affiliation_Agreement_01-29-21.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 125	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	125	125
Annual IC Time Burden (Hours)	31	31
Annual IC Cost Burden (Dollars)	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.