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

IC 8133 under ICR 202310-0938-001 · OMB 0938-0512.

Documents and Forms
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Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348
 
No Modified
 
Mandatory
 

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

Health Health Care Services

Orgran Procurement Organization System (OPOS)  71 FR 29336

16 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

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

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.