Off-cycle Submission of Summaries (MOC Changes)

Initial and Renewal Model of Care Submissions, and Off-cycle Submission of Summaries of Model of Care Changes (CMS-10565)

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.