Information Collection

Participation Agreement

IC 244606 under ICR 202305-0938-016 · OMB 0938-1388.

Documents and Forms

Document Name Document Type
Form CMS-10728 Participation Agreement Form and Instruction
CMS-10728 Patient Agreement ViT PA Final clean 10.15.2020.docx Form and Instruction
CMS-10728 Patient Agreement ViT PA Final clean 10.15.2020.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participation Agreement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10728	Patient Agreement	ViT PA Final clean 10.15.2020.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-100	100
Annual IC Time Burden (Hours)	-200	200
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.