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Federal forms, ICRs, and supporting documents

Information Collection

Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators

IC 254942 under ICR 202212-0938-003 · OMB 0938-1425.

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Document Type
Form
Instruction
Instruction
Form
Form
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Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators
 
No Modified
 
Voluntary
 
42 CFR 413.24 42 CFR 413.20

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10821 Supplement to Form CMS-2552-10 CMS-10821. Supplement to Form CMS-2552-10-f (form).pdf Yes Yes Fillable Fileable
Instruction CMS-10821. Supplemental to Form CMS-2552-10-i (instructions).pdf Yes Yes Fillable Fileable

Health Health Care Services

 

4,662 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,662 0 4,662 0 0 0
Annual IC Time Burden (Hours) 2,331 0 2,331 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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