155.225(b)(1) (organization follow-up for application)

Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel - CAC (CMS-10494)

Documents and Forms

Document Name Document Type
Form CMS-10494 155.225(b)(1) (organization follow-up for application) Form and Instruction
CMS-10494 CAC Organization Application CMS-10494-Appendix A_CAC Online Application.pdf Form and Instruction
CMS-10494 CAC Organization Application CMS-10494-Appendix A_CAC Online Application.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	155.225(b)(1) (organization follow-up for application)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.225(b)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	CAC Organization Application	CMS-10494-Appendix A_CAC Online Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	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: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	500	500
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.