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Federal forms, ICRs, and supporting documents

Information Collection

DE Entity Operational Readiness Review (ORR)

IC 263264 under ICR 202311-0938-002 · OMB 0938-1463.

Documents and Forms
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Information Collection (IC) Details

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DE Entity Operational Readiness Review (ORR) CCIIO - 10877
 
No New
 
Required to Obtain or Retain Benefits
 
45 CFR 155.221

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10877 Documentation and Audit Package CMS-10877 - Appendix_E_DEE-Documentation-Package.pdf Yes No Paper Only
Form and Instruction CMS-10877 Privacy Questiionaire CMS-10877 - Appendix_F_EDE-Privacy-Questionnaire.pdf Yes Yes Fillable Fileable
Instruction CMS-10877 - Appendix_G_API-Functional-Integration-Toolkit.pdf Yes No Paper Only
Form and Instruction CMS-10877 Application User Interface Toolkit CMS-10877 - Appendix_H_Application-UI-Toolkit.pdf Yes No Fillable Printable
Form and Instruction CMS-10877 Communications Toolkit CMS-10877 - Appendix_J_EDE-Business-Audit-Instructions-Report-Template.pdf Yes Yes Paper Only
Form and Instruction CMS-10877 Eligibility Results Toolkit CMS-10877 - Appendix_K_EDE-Eligibility-Results-Toolkit-Phase1.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 Eligibility Results Toolkit - Phase 2 CMS-10877 - Appendix_L_EDE-Eligibility-Results-Toolkit-Phase2.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 Eligibility Results Toolkit - Phase 3 CMS-10877 - Appendix_M_EDE-Eligibility-Results-Toolkit-Phase3.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 Change Notification Form CMS-10877 - Appendix_N_EDE-Entity-Initiated-Change-Notification-Form_v2_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10877 Business Agreement BY 2024 CMS-10877 - Appendix_O_EDE_Business_Agreement_PY_2024_Final_508.pdf Yes Yes Fillable Fileable
Form CMS-10877 INTERCONNECTION SECURITY AGREEMENT CMS-10877 - Appendix_Q_CMS-EDE-ISA-Template.pdf Yes No Fillable Fileable

Health Health Care Services

 

95 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested 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 95 95 0 0 0 0
Annual IC Time Burden (Hours) 2,689 2,689 0 0 0 0
Annual IC Cost Burden (Dollars) 200,372 200,372 0 0 0 0

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