Information Collection

RIF Request Packet

IC 8408 under ICR 202204-0938-004 · OMB 0938-0734.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0734 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-235 RIF Request Packet	Form and Instruction
CMS-R-235 Data Use Agreement (DUA) Form-R-0235 DUA.pdf	Form and Instruction
CMS-R-235 Data Use Agreement (DUA) Form-R-0235 DUA.pdf	Form and Instruction
CMS-R-235 RIF Request Application 02AttachmentA-RIF-Application-508.docx	Form and Instruction
CMS-R-235 RIF Request Application 02AttachmentA-RIF-Application-508.docx	Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf	Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf	Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf	Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf	Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx	Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx	Form and Instruction

IC Title:

RIF Request Packet

Agency IC Tracking Number:

CMS-R-235

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-R-235	Data Use Agreement (DUA)	Form-R-0235 DUA.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	RIF Request Application	02AttachmentA-RIF-Application-508.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	State Agency Supplement	06State-Agency-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Innovator Supplement	05Innovator-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Collaborator Supplement	04Collaborator-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Key Personnel Supplement	03Key-Personnel-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Amendment Request Form	08RIF-Amendment-final-508.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,705

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,705	-6,495	9,200
Annual IC Time Burden (Hours)	1,249	-1,651	2,900
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.