Information Collection

Attestations

IC 229160 under ICR 202106-0938-007 · OMB 0938-1023.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10209 Attestations	Form
CMS-10209 CCIP Attestation 2020 CCIP Attestation screenshot.pdf	Form

IC Title:

Attestations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-10209	CCIP Attestation	2020 CCIP Attestation screenshot.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 645

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	645	-105	750
Annual IC Time Burden (Hours)	161	-27	188
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.