Information Collection

Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals)

IC 248590 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10495 Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals) Form
CMS-10495 Dispute Resolution and Correction CMS-10495 - Review And Dispute Screen Shots 9.23.2020 - 508 cf.pdf Form
CMS-10495 Dispute Resolution and Correction CMS-10495 - Review And Dispute Screen Shots 9.23.2020 - 508 cf.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-10495	Dispute Resolution and Correction	CMS-10495 - Review And Dispute 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: 1,996	Number of Respondents for Small Entity: 1,996

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
Annual Number of Responses for this IC	1,996	1,996
Annual IC Time Burden (Hours)	772	772
Annual IC Cost Burden (Dollars)	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.