Information Collection

PaRIS Eligibility Screener

IC 251722 under ICR 202202-0938-004 · OMB 0938-1434.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10792 PaRIS Eligibility Screener	Form and Instruction
CMS-10792 PaRIS Eligibility Screener Attachment 2. PaRIS Specifications.pdf	Form and Instruction
Attach2_PaRIS_Showcards.pdf Showcards	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Form and Instruction	CMS-10792	PaRIS Eligibility Screener	Attachment 2. PaRIS Specifications.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Current Beneficiary Survey (MCBS)

FR Citation: 83 FR 6591

Number of Respondents: 7,348

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,348	7,348
Annual IC Time Burden (Hours)	367	367
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Showcards	Attach2_PaRIS_Showcards.pdf	03/02/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.