Information Collection

Supplemental Diagnosis

IC 211708 under ICR 202308-0938-015 · OMB 0938-1155.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1155 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10401 - Appendix A 3Rs.pdf	Other-Data Elements
CMS-10401 - Appendix A 3Rs.pdf	Other-Data Elements

IC Title:

Supplemental Diagnosis

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.700(a)

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
Other-Data Elements			CMS-10401 - Appendix A 3Rs.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 650

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	650	650
Annual IC Time Burden (Hours)	374,400	374,400
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.