Information Collection

Preparation and Issuance of Model Notices (section 423.120(c)(6))

IC 231341 under ICR 202302-0938-009 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10141 Preparation and Issuance of Model Notices (section 423.120(c)(6)) Form and Instruction
CMS-10141 Model Precluded Provider Letter Attachment 2. Part C and D Model Precluded Provider Letter.pdf Form and Instruction
CMS-10141 Model Precluded Provider Letter Attachment 2. Part C and D Model Precluded Provider Letter.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Preparation and Issuance of Model Notices (section 423.120(c)(6))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.120(c)(6)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10141	Model Precluded Provider Letter	Attachment 2. Part C and D Model Precluded Provider Letter.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	1,245	1,245
Annual IC Cost Burden (Dollars)	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.