Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348

Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 (CMS-576 and CMS-576A)

Documents and Forms

Document Name Document Type
Form CMS-576A Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 Form and Instruction
CMS-576A Health Insurance Benefits Agreement CMS-576A form. 03.23.23.pdf Form and Instruction
CMS-576A Health Insurance Benefits Agreement CMS-576A form. 03.23.23.pdf Form and Instruction
CMS-576 ORGAN PROCUREMENT ORGANIZATION (OPO) REQUEST FOR DESIGNA CMS-576 form..03.23.23.pdf Form and Instruction
CMS-576 ORGAN PROCUREMENT ORGANIZATION (OPO) REQUEST FOR DESIGNA CMS-576 form..03.23.23.pdf Form and Instruction
Change Crosswalk for CMS-576. 03.23.23.pdf Crosswalk IC Document
Change Crosswalk for CMS-576. 03.23.23.pdf Crosswalk IC Document
Change Crosswalk for CMS-576A 03.21.23.pdf Crosswalk IC Document
Change Crosswalk for CMS-576A 03.21.23.pdf Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-576A	Health Insurance Benefits Agreement	CMS-576A form. 03.23.23.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-576	ORGAN PROCUREMENT ORGANIZATION (OPO) REQUEST FOR DESIGNATION AS AN OPO	CMS-576 form..03.23.23.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Orgran Procurement Organization System (OPOS)	FR Citation: 71 FR 29336

Number of Respondents: 16	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: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	16	-42	58
Annual IC Time Burden (Hours)	32	3	29
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-576. 03.23.23.pdf	10/18/2023
Crosswalk	Change Crosswalk for CMS-576A 03.21.23.pdf	10/18/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.