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.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10821 Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	Form
CMS-10821. Supplemental to Form CMS-2552-10-i (instructions).pdf	Instruction
CMS-10821. Supplemental to Form CMS-2552-10-i (instructions).pdf	Instruction
CMS-10821 Supplement to Form CMS-2552-10 CMS-10821. Supplement to Form CMS-2552-10-f (form).pdf	Form
CMS-10821 Supplement to Form CMS-2552-10 CMS-10821. Supplement to Form CMS-2552-10-f (form).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 413.24 42 CFR 413.20

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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,662

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	4,662	4,662
Annual IC Time Burden (Hours)	2,331	2,331
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.