Information Collection

Requests for Mailed Disclosures

IC 249943 under ICR 202110-0938-016 · OMB 0938-1429.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1429 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10715-Transparency in Coverage_Appendix 1_Final.pdf	Other-Instruction

IC Title:

Requests for Mailed Disclosures

Agency IC Tracking Number:

CCIIO - 10715

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.210(b)(2)(ii)

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
Other-Instruction			CMS-10715-Transparency in Coverage_Appendix 1_Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 653

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 54 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	42,463	42,463
Annual IC Time Burden (Hours)	10,616	10,616
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.