State Implemented Moratorium Form

Initial Request for State Implemented Moratorium Form (CMS-10628)

OMB: 0938-1328

IC ID: 224647

Information Collection (IC) Details

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State Implemented Moratorium Form CPI - 10628
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 455.470

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10628 State Moratoria Request Form CMS-10628-State Moratorium Form-508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

5 0
   
State, Local, and Tribal Governments
 
   0 %

  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 5 0 0 -10 15 0
Annual IC Time Burden (Hours) 25 0 0 -50 75 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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