Information Collection

Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)

IC 266611 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10892 Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)	Form and Instruction
CMS-10892 Emergency Medical Treatment and Labor Act (EMTALA) Compl CMS-10892.Fast Track - EMTALA - Mockup - final- 04032024.pdf	Form and Instruction
CMS-10892.Fast Track - GenIC Template (EMTALA).docx CMS-10892.Fast Track - GenIC Template (EMTALA)	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-10892				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: ASPEN Complaints/Incidents Tracking System (ACTS) 09-70-0565

FR Citation: 71 FR 29643

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10892.Fast Track - GenIC Template (EMTALA)		04/05/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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