Information Collection

Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form

IC 223444 under ICR 202110-0938-007 · OMB 0938-0948.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0948 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10148 Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form Form
CMS-10148 HIPAA Administrative Simplification (Non-Privacy) Compla CMS-10148. HIPAA Administrative Simplification (Non-Privacy) Complaint Form - (06092021).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10148	HIPAA Administrative Simplification (Non-Privacy) Complaint Form	CMS-10148. HIPAA Administrative Simplification (Non-Privacy) Complaint Form - (06092021).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Program Information Management System (PIMS)	FR Citation: 75 FR 18841

Number of Respondents: 21	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21	-104	125
Annual IC Time Burden (Hours)	21	-104	125
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.