Essential Community Provider Petition

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

OMB: 0938-1295

IC ID: 218061

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Essential Community Provider Petition
No Modified
Required to Obtain or Retain Benefits

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

Health Public Health Monitoring


12,408 0
Private Sector Businesses or other for-profits, Not-for-profit institutions
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 12,408 0 0 -2,550 14,958 0
Annual IC Time Burden (Hours) 9,420 0 0 -12,984 22,404 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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