Essential Community Provider Petition

Essential Community Provider Data Collection to Support QHP Certification (CMS-10561)

Documents and Forms

Document Name Document Type
CMS-10561 ECP Provider Petition Instructions.pdf Instruction
CMS-10561 ECP Provider Petition Instructions.pdf Instruction

Information Collection (IC) Details

IC Title:	Essential Community Provider Petition	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10561 ECP Provider Petition Instructions.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,408	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: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	12,408	-2,550	14,958
Annual IC Time Burden (Hours)	9,420	-12,984	22,404
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.