Application Requirements (POs)

The PACE Organization Application Process in 42 CFR Part 460 (CMS-10631)

Documents and Forms

Document Name Document Type
Form CMS-10631 Application Requirements (POs) Form and Instruction
CMS-10631 PACE Application PACE Paper Application_FINAL_01102022.pdf Form and Instruction
CMS-10631 PACE Application PACE Paper Application_FINAL_01102022.pdf Form and Instruction
CMS-10631 HPMS_ SAE PACE Application PACE Blank Attestations - SAE.pdf Form and Instruction
CMS-10631 HPMS_ SAE PACE Application PACE Blank Attestations - SAE.pdf Form and Instruction
CMS-10631 HPMS_ Initial PACE Application PACE Blank Attestations - Initial.pdf Form and Instruction
CMS-10631 HPMS_ Initial PACE Application PACE Blank Attestations - Initial.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application Requirements (POs)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.12(a)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10631	PACE Application	PACE Paper Application_FINAL_01102022.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10631	HPMS_ SAE PACE Application	PACE Blank Attestations - SAE.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10631	HPMS_ Initial PACE Application	PACE Blank Attestations - Initial.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	45	0	45
Annual IC Time Burden (Hours)	2,595	45	2,550
Annual IC Cost Burden (Dollars)	0	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.