Information Collection

Supplemental Diagnosis (153.700(a))

IC 211708 under ICR 202209-0938-002 · OMB 0938-1155.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1155 can be found here:

Documents and Forms

Document Name Document Type
CMS-10401 Appendix A 3Rs PRA__508.pdf Other-Data Elements
CMS-10401 Appendix A 3Rs PRA__508.pdf Other-Data Elements

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Diagnosis (153.700(a))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.700(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Data Elements			CMS-10401 Appendix A 3Rs PRA__508.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 650	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	Previously Approved
Annual Number of Responses for this IC	650	650
Annual IC Time Burden (Hours)	374,400	374,400
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.