Information Collection

Internet-based Self-Service Tool

IC 238757 under ICR 202110-0938-009 · OMB 0938-1372.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10715: Appendi Internet-based Self-Service Tool	Form and Instruction
CMS-10715: Appendi APPENDIX 2: In-network Rate Machine-Readable File Data E CMS-10715-Transparency in Coverage_Appendix 2_Final .pdf	Form and Instruction
CMS-10715: Appendi APPENDIX 2: In-network Rate Machine-Readable File Data E CMS-10715-Transparency in Coverage_Appendix 2_Final .pdf	Form and Instruction
CMS-10715: Appendi APPENDIX 3: The Allowed Amount Machine-Readable File Dat CMS-10715-Transparency in Coverage_Appendix 3_.pdf	Form and Instruction
CMS-10715: Appendi APPENDIX 3: The Allowed Amount Machine-Readable File Dat CMS-10715-Transparency in Coverage_Appendix 3_.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 47 CFR 147.210(b)(2)(i)

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 and Instruction	CMS-10715: Appendix 2	APPENDIX 2: In-network Rate Machine-Readable File Data Elements	CMS-10715-Transparency in Coverage_Appendix 2_Final .pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10715: Appendix 3	APPENDIX 3: The Allowed Amount Machine-Readable File Data Elements	CMS-10715-Transparency in Coverage_Appendix 3_.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 980

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	980	980
Annual IC Time Burden (Hours)	22,835,410	22,835,410
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.