Information Collection Request

Value in Opioid Use Disorder Treatment Demonstration (CMS-10728)

ICR 202305-0938-016 · OMB 0938-1388 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form CMS-10728 Participation Agreement	Form and Instruction	Removed	Repair queued
Form CMS-10728 Participant Survey	Form and Instruction	Modified	Repair queued
Form CMS-10728 Beneficiary Survey	Form and Instruction	Modified	Repair queued
Form CMS-10728 Beneficiary Notification	Form and Instruction	Modified	Repair queued
Form CMS-10728 Request for Application	Form and Instruction	Modified	Repair queued
CMS-10728_OUD_Supporting Statement - Part A.docx	Supporting Statement A	Uploaded 2023-05-31	Missing upstream
Value in Treatment 2022 Amendment No. 1 Sequestration (003).pdf	Supplementary Document	Uploaded 2023-05-31	Repair queued
ViT RFA Attachment 2 prevalence rates.xlsx	Supplementary Document	Uploaded 2020-12-03	Repair queued
ViT_OUD_Diagnosis_Codes.pdf	Supplementary Document	Uploaded 2023-05-31	Repair queued
ViT PA Final clean 3.25.2021.pdf	Supplementary Document	Uploaded 2023-05-31	Repair queued

Information collection document groups
IC ID	Collection	Type	Status
244606	Participation Agreement	Form and Instruction	Removed
242941	Participant Financial	Instruction	Modified
242940	Participant Compliance Audit	Instruction	Modified
242939	Participant Survey	Form and Instruction	Modified
242934	Beneficiary Survey	Form and Instruction	Modified
242933	Beneficiary Notification	Form and Instruction	Modified
242932	Request for Application	Form and Instruction	Modified

Record metadata
Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1388
Type of Information Collection	Extension without change of a currently approved collection
Previous ICR Reference No	202007-0938-012
Agency Tracking No	CMMI
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31