Information Collection

DDR Quarterly Pricing Data (CMS-367a)

IC 8184 under ICR 202304-0938-029 · OMB 0938-0578.

Documents and Forms

Document Name Document Type
Form CMS-376a DDR Quarterly Pricing Data (CMS-367a) Form
CMS-367a Instruction Screenshots_09.2021.pdf Instruction
CMS-367a Instruction Screenshots_09.2021.pdf Instruction
CMS-376a Quarterly Pricing Data CMS-367a Data Entry Screenshots_09.2021.pdf Form
CMS-376a Quarterly Pricing Data CMS-367a Data Entry Screenshots_09.2021.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	DDR Quarterly Pricing Data (CMS-367a)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-376a	Quarterly Pricing Data	CMS-367a Data Entry Screenshots_09.2021.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS-367a Instruction Screenshots_09.2021.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 818	Number of Respondents for Small Entity: 100

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,272	152	3,120
Annual IC Time Burden (Hours)	113,866	5,290	108,576
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.