D-SNP Enrollee Advisory Committee and SNP Standardized Questions on Health Risk Assessments

D-SNP Enrollee Advisory Committee and SNP Standardized Questions on Health Risk Assessments (CMS-10799)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1422 can be found here:

Documents and Forms

Document Name Document Type
Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessme Instruction
Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessme Instruction

Information Collection (IC) Details

IC Title:	D-SNP Enrollee Advisory Committee and SNP Standardized Questions on Health Risk Assessments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Instruction			Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessment (CMS-4192-P version 2).pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 383	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: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	383	383
Annual IC Time Burden (Hours)	10,769	10,769
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.