155.225(b)(1)(i) (certificate issuance)

Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel - CAC (CMS-10494)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1205 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10494 155.225(b)(1)(i) (certificate issuance) Form and Instruction
CMS-10494 Training Certificate CMS-10494 - Appendix E_ SampleTraining Completion Certificate (1).docx Form and Instruction
CMS-10494 Training Certificate CMS-10494 - Appendix E_ SampleTraining Completion Certificate (1).docx Form and Instruction
CMS-10494 Training Certificate (English) CMS-10494 - Appendix H_Sample Certification Certificate English.docx Form and Instruction
CMS-10494 Training Certificate (English) CMS-10494 - Appendix H_Sample Certification Certificate English.docx Form and Instruction
CMS-10494 Sample Certification Certificate (Spanish) CMS-10494 - Appendix I_Sample Certification Certificate Spanish.docx Form and Instruction
CMS-10494 Sample Certification Certificate (Spanish) CMS-10494 - Appendix I_Sample Certification Certificate Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	155.225(b)(1)(i) (certificate issuance)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.225(b)(1)(i)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	Training Certificate	CMS-10494 - Appendix E_ SampleTraining Completion Certificate (1).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10494	Training Certificate (English)	CMS-10494 - Appendix H_Sample Certification Certificate English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10494	Sample Certification Certificate (Spanish)	CMS-10494 - Appendix I_Sample Certification Certificate Spanish.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	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: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	480	480
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.