Information Collection

Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators

IC 254942 under ICR 202207-0938-017 · OMB 0938-1425.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1425 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10821 Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators Form
CMS-10821. Supplemental to Form CMS-2552-10-i (instructions).pdf Instruction
CMS-10821. Supplemental to Form CMS-2552-10-i (instructions).pdf Instruction
CMS-10821 Supplement to Form CMS-2552-10 CMS-10821. Supplement to Form CMS-2552-10-f (form).pdf Form
CMS-10821 Supplement to Form CMS-2552-10 CMS-10821. Supplement to Form CMS-2552-10-f (form).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 413.24 42 CFR 413.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10821	Supplement to Form CMS-2552-10	CMS-10821. Supplement to Form CMS-2552-10-f (form).pdf		Yes	Yes	Fillable Fileable
Instruction			CMS-10821. Supplemental to Form CMS-2552-10-i (instructions).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,662	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: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,662	4,662
Annual IC Time Burden (Hours)	2,331	2,331
Annual IC Cost Burden (Dollars)	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.