Health Reimbursement Arrangements

Health Reimbursement Arrangements and Other Account-Based Group Health Plans (CMS-10704)

Documents and Forms

Document Name Document Type
Form CMS-10704 Health Reimbursement Arrangements Form and Instruction
CMS-10704 Model Notice CMS-10704 - HRA Model Notice.pdf Form and Instruction
CMS-10704 Model Notice CMS-10704 - HRA Model Notice.pdf Form and Instruction
CMS-10704 Model Attestation CMS-10704 Attachment HRA Model Attestation.pdf Form and Instruction
CMS-10704 Model Attestation CMS-10704 Attachment HRA Model Attestation.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Reimbursement Arrangements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 146.123(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10704	Model Notice	CMS-10704 - HRA Model Notice.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10704	Model Attestation	CMS-10704 Attachment HRA Model Attestation.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,673	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	849,442	-5,485	582,247	272,680
Annual IC Time Burden (Hours)	5,890	68	-194	6,016
Annual IC Cost Burden (Dollars)	0	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.