OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

SBC Disclosure

IC 199007 under ICR 202210-0938-011 · OMB 0938-1146.

Documents and Forms
Document Name
Document Type
Other-Maternity Care Narrative
Other-Maternity Care Narrative
Other-Diabetes 2 Narrative
Other-Diabetes 2 Narrative
Other-Uniform Glossary Anchor
Other-Uniform Glossary Anchor
Other-What the Plan Covers and What
Other-What the Plan Covers and What
Other-Why This Matters for SBC (Yes
Other-Why This Matters for SBC (Yes
Instruction
Instruction
Instruction
Instruction
Other-Completed SBC Template
Other-Completed SBC Template
Other-SBC Template
Other-SBC Template
Other-Foot Fracture Narrative
Other-Foot Fracture Narrative
Instruction
Instruction
Other-Coverage Calculator
Other-Coverage Calculator
Other-Template
Other-Template
Other-Diabetes Guide
Other-Diabetes Guide
Other-Glossary Anchor
Other-Glossary Anchor
Other-Template
Other-Template
Instruction
Instruction
Instruction
Instruction
Other-Uniform Glossary
Other-Uniform Glossary
Form
Information Collection (IC) Details

View Information Collection (IC)

SBC Disclosure
 
No Modified
 
Mandatory
 
45 CFR 147.200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Maternity Care Narrative Maternity-Care-Narrative-05-05-22.pdf Yes No Printable Only
Other-Diabetes 2 Narrative SBC_Diabetes-Narrative-051222 508.pdf Yes No Printable Only
Other-Uniform Glossary Anchor Uniform-Glossary-051222 508.pdf Yes No Printable Only
Other-What the Plan Covers and What You Pay (No Answers) Why This Matters language for SBC_No-Answers-English-051222 508.pdf Yes No Printable Only
Other-Why This Matters for SBC (Yes Answers) Why This Matters language for SBC_Yes-Answers-English-051222 508.pdf Yes No Printable Only
Instruction Group-Instructions-051222 508.pdf Yes No Printable Only
Instruction Individual-Instructions-051222 508.pdf Yes No Printable Only
Other-Completed SBC Template Sample-Completed-SBC-Accessible-Format 051222.pdf Yes No Fillable Fileable
Other-SBC Template Sample-Completed-SBC-Accessible-Format 051222.pdf Yes No Fillable Fileable
Other-Foot Fracture Narrative Foot-Fracture-Narrative-051222 508.pdf Yes No Printable Only
Instruction Coverage-Examples-Calculator-Instructions-051222 508.pdf Yes No Printable Only
Other-Coverage Calculator Coverage-Examples-Calculator-Instructions-051222 508.pdf Yes No Fillable Printable
Other-Template Having-a-Baby-Guide-051222 508.pdf Yes No Printable Only
Other-Diabetes Guide Managing-Type-2-Diabetes-Guide-051222 508.pdf Yes No Printable Only
Other-Glossary Anchor Uniform-Glossary-051222 508.pdf Yes No Printable Only
Other-Template Simple-Fracture-Guide-051222 508.pdf Yes No Printable Only
Instruction AIAN Limited Cost Sharing.pdf Yes No Printable Only
Instruction AIAN_Zero_Cost_Sharing.pdf Yes No Printable Only
Other-Uniform Glossary Uniform-Glossary-051222 508.pdf Yes No Printable Only
Form CMS-10407 SBC Template SBC-Template-Accessible-Format.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

679 35
   
Private Sector Businesses or other for-profits
 
   70 %

  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 24,211,211 0 0 -17,593,417 0 41,804,628
Annual IC Time Burden (Hours) 203,564 0 0 -11,227 0 214,791
Annual IC Cost Burden (Dollars) 10,494,154 0 0 6,313,691 0 4,180,463

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.