Notification of Non-compliance (Self-Insured Non-Federal Governmental Plans and Issuers)

Non-Quantitative Treatment Limitation Analyses and Compliance Under MHPAEA (CMS-10773)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1393 can be found here:

Documents and Forms

Document Name Document Type
CMS-10773 Appendix I - FAQs-Part-45.docx Other-Guidance
CMS-10773 Appendix I - FAQs-Part-45.docx Other-Guidance

Information Collection (IC) Details

IC Title:	Notification of Non-compliance (Self-Insured Non-Federal Governmental Plans and Issuers)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Guidance			CMS-10773 Appendix I - FAQs-Part-45.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
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.