SHOP - Employer

Data Collection to Support Eligibility Determinations and Enrollment for Small Businesses in the Small Business Health Options Program (CMS-10439)

Documents and Forms

Document Name Document Type
Form CMS-10439 SHOP - Employer Form and Instruction
CMS-10439 Appendix 1 - SHOP Application Eligibility Form CMS-10439_SHOP_Application_Eligibility_Form.pdf Form and Instruction
CMS-10439 Appendix 1 - SHOP Application Eligibility Form CMS-10439_SHOP_Application_Eligibility_Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	SHOP - Employer	Agency IC Tracking Number:	CCIIO - 10439

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.710 45 CFR 155.410 45 CFR 155.731

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10439	Appendix 1 - SHOP Application Eligibility Form	CMS-10439_SHOP_Application_Eligibility_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: 2,100	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,100	-3,900	6,000
Annual IC Time Burden (Hours)	336	-624	960
Annual IC Cost Burden (Dollars)	0	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.