Information Collection

155.225(b)(1) Organization designation by Exchange Information Updates

IC 216272 under ICR 202210-0938-013 · OMB 0938-1205.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10494 155.225(b)(1) Organization designation by Exchange Information Updates	Form and Instruction
CMS-10494 Find Local Help Instrument CMS-10494 - Appendix C_Find Local Help.docx	Form and Instruction
CMS-10494 Find Local Help Instrument CMS-10494 - Appendix C_Find Local Help.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 155.225

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	Find Local Help Instrument	CMS-10494 - Appendix C_Find Local Help.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	3,750	3,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.