Information Collection

Health Reimbursement Arrangements

IC 236410 under ICR 202306-0938-008 · OMB 0938-1361.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.