Information Collection

Application Requirements (POs)

IC 223821 under ICR 202204-0938-003 · OMB 0938-1326.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1326 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.