Information Collection

Updated Contact Information: AM and Applicable GPO Attestations

IC 248584 under ICR 202107-0938-014 · OMB 0938-1237.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1237 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10495 Updated Contact Information: AM and Applicable GPO Attestations	Form
CMS-10495 Attestation and Assumptions CMS-10495 - Attestation and Assumptions Screen Shots 9.23.2020 - 508 cf.pdf	Form
CMS-10495 Attestation and Assumptions CMS-10495 - Attestation and Assumptions Screen Shots 9.23.2020 - 508 cf.pdf	Form

IC Title:

Updated Contact Information: AM and Applicable GPO Attestations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-10495	Attestation and Assumptions	CMS-10495 - Attestation and Assumptions Screen Shots 9.23.2020 - 508 cf.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 30

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
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	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.