Information Collection

Internet-based Self-Service Tool

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Internet-based Self-Service Tool	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:

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 %

	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

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.