Information Collection

Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)

IC 270304 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10903 CMS-10903. Attachment A - Generative In-Depth Interview Guide Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	Form and Instruction
Form CMS-10903.Attachme CMS-10903.Attachment B - Medicare Enrollee Eligibility Screener Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	Form and Instruction
Form CMS-10903 CMS-10903. Attachment C - Consent form Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	Form and Instruction
CMS-10903 CMS-10903. Attachment A - Generative In-Depth Interview CMS-10903. Attachment A - Generative In-Depth Interview Guide.docx	Form and Instruction
CMS-10903.Attachme CMS-10903.Attachment B - Medicare Enrollee Eligibility S CMS-10903.Attachment B - Medicare Enrollee Eligibility Screener.docx	Form and Instruction
CMS-10903 CMS-10903. Attachment C - Consent form CMS-10903. Attachment C - Consent form.docx	Form and Instruction
CMS-10903. GenIC Submission Template.docx CMS-10903. GenIC Submission Template	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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10903	Yes	No	Fillable Fileable
Form and Instruction	CMS-10903.Attachment B	Yes	No	Fillable Fileable
Form and Instruction	CMS-10903	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,220

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	1,220	1,220
Annual IC Time Burden (Hours)	222	222
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10903. GenIC Submission Template		08/21/2024

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

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