Information Collection

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

IC 249054 under ICR 202108-0938-013 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Reporting Requirements Regarding Air Ambulance Services â 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:

table that charts list of 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 %

table that charts list of burden
	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

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.