Information Collection

Off-cycle Submission of Summaries (MOC Changes)

IC 218542 under ICR 202105-0938-005 · OMB 0938-1296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1296 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10565 Off-cycle Submission of Summaries (MOC Changes)	Form
CMS-10565 Revised Model of Care Matrix Upload Document Attachment B_Model_of_Care_Matrix_Off Cycle Submission V2.pdf	Form

IC Title:

Off-cycle Submission of Summaries (MOC Changes)

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10565	Revised Model of Care Matrix Upload Document	Attachment B_Model_of_Care_Matrix_Off Cycle Submission V2.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 139

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	139	36	103
Annual IC Time Burden (Hours)	556	144	412
Annual IC Cost Burden (Dollars)	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.