Information Collection Request
Initial Request for State Implemented Moratorium Form (CMS-10628)
ICR 202301-0938-007 · OMB 0938-1328 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1328 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-10628 State Implemented Moratorium Form |
Form and Instruction | Modified | Repair queued |
 CMS-10628 - Supporting Statement for Enrollment Moratorium R.docx |
Supporting Statement A | Uploaded 2023-01-20 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 224647 |  State Implemented Moratorium Form |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1328 |
| Type of Information Collection | Reinstatement without change of a previously approved collection |
| Previous ICR Reference No | 201611-0938-020 |
| Agency Tracking No | CPI -10628 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |