Attestations

Medicare Advantage Chronic Care Improvement Program (CCIP) Attestations (CMS-10209)

Documents and Forms

Document Name Document Type
Form CMS-10209 Attestations Form
CMS-10209 CCIP Attestation 2020 CCIP Attestation screenshot.pdf Form

Information Collection (IC) Details

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:

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 %

	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

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.