Information Collection

Procedure Nominations

IC 261757 under ICR 202308-0938-013 · OMB 0938-1458.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10809 Procedure Nominations	Form and Instruction
Form CMS-10809 ASC CPL Pre-Proposed Rule Recommendation Request Procedure Nominations	Form and Instruction
Form CMS-10809 MEARIS Screenshots Procedure Nominations	Form and Instruction
CMS-10809 ASC CPL Pre-Proposed Rule Recommendation Request ASC CPL Pre-Proposed Rule Recommendation Request.pdf	Form and Instruction
CMS-10809 ASC CPL Pre-Proposed Rule Recommendation Request ASC CPL Pre-Proposed Rule Recommendation Request.pdf	Form and Instruction
CMS-10809 MEARIS Screenshots MEARIS Screenshots.pdf	Form and Instruction
CMS-10809 MEARIS Screenshots MEARIS Screenshots.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 416 Sec 2 42 CFR 416 Sec 166

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-10809				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10809				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
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.

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