Reporting Requirements Regarding Air Ambulance Services – Plans, Issuers, and FEHB carriers

Reporting Requirements Regarding Air Ambulance Services (CMS-10785)

Documents and Forms

Document Name Document Type
AA Report Instructions - Plans Issuers Carriers revised.pdf Instruction
AA Report Instructions - Plans Issuers Carriers revised.pdf Instruction
CMS-10785 Air Ambulance Template - Plan Issuers Carriers AA Report Template - Plans Issuers Carriers.pdf Form
CMS-10785 Air Ambulance Template - Plan Issuers Carriers AA Report Template - Plans Issuers Carriers.pdf Form

Information Collection (IC) Details

IC Title:	Reporting Requirements Regarding Air Ambulance Services – Plans, Issuers, and FEHB carriers	Agency IC Tracking Number:	CCIIO-10785

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.230

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			AA Report Instructions - Plans Issuers Carriers revised.pdf		Yes	No	Paper Only
Form	CMS-10785	Air Ambulance Template - Plan Issuers Carriers	AA Report Template - Plans Issuers Carriers.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 326	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: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	326	326
Annual IC Time Burden (Hours)	7,819	7,819
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.