Information Collection

Collection of User Fee Adjustment Information from FFE (or SBE-FP) Participating Issuers

IC 258183 under ICR 202302-0938-001 · OMB 0938-1285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1285 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10492 - Issuer data elements for FFE Adjustment rev.pdf	Instruction
CMS-10492 - Issuer data elements for FFE Adjustment rev.pdf	Instruction

IC Title:

Collection of User Fee Adjustment Information from FFE (or SBE-FP) Participating Issuers

Agency IC Tracking Number:

CCIIO -10492

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.50(d)(2)

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
Instruction			CMS-10492 - Issuer data elements for FFE Adjustment rev.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	200	200
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.