Information Collection

Monthly Data Submission Accuracy Certification Form

IC 209729 under ICR 202204-0938-012 · OMB 0938-1217.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1217 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10515 Monthly Data Submission Accuracy Certification Form	Form and Instruction
CMS-10515 Monthly Data Submission Accuracy Certification Form CMS-10515_Certification Tab_update_508.xlsx	Form and Instruction
CMS-10515 Monthly Data Submission Accuracy Certification Form CMS-10515_Certification Tab_update_508.xlsx	Form and Instruction

IC Title:

Monthly Data Submission Accuracy Certification Form

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10515	Monthly Data Submission Accuracy Certification Form	CMS-10515_Certification Tab_update_508.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	300	-600	900
Annual IC Time Burden (Hours)	51	-102	153
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.