Information Collection

Disclosure of State Rating Requirements

IC 208568 under ICR 202212-0938-001 · OMB 0938-1258.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1258 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10454 Disclosure of State Rating Requirements Form and Instruction
CMS-10454 State Rating Requirements Disclosure Form CMS-10454 - State Rating Requirements Disclosure Form.pdf Form and Instruction
CMS-10454 State Rating Requirements Disclosure Form CMS-10454 - State Rating Requirements Disclosure Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disclosure of State Rating Requirements	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 147.102

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10454	State Rating Requirements Disclosure Form	CMS-10454 - State Rating Requirements Disclosure Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	17	17
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.