Information Collection

Essential Community Provider Petition

IC 218061 under ICR 202206-0938-008 · OMB 0938-1295.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1295 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10561 ECP Provider Petition Instructions.pdf	Instruction
CMS-10561 ECP Provider Petition Instructions.pdf	Instruction

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:

table that charts list of 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 %

table that charts list of burden
	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

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.