Information Collection

General Public (individual and organization)

IC 260900 under ICR 202306-0938-013 · OMB 0938-1449.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10847 General Public (individual and organization)	Form and Instruction
CMS-10847 Negotiation Data Elements Form Negotiation Data Elements ICR_508 final.pdf	Form and Instruction
CMS-10847 Negotiation Data Elements Form Clean Final NDE ICR FINAL.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10847	Negotiation Data Elements Form	Clean Final NDE ICR FINAL.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,300	3,300
Annual IC Time Burden (Hours)	12,000	12,000
Annual IC Cost Burden (Dollars)	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.