Information Collection

GenIC #11 - Notice Testing: CMS Notice of Change of Status (CMS-10868)

IC 269259 under ICR 202402-0938-008 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10710.GenIC#11 CMS-10710 GenIC#11. (CMS 10868) Change of Status Instrument GenIC #11 - Notice Testing: CMS Notice of Change of Status (CMS-10868)	Form and Instruction
CMS-10710.GenIC#11 CMS-10710 GenIC#11. (CMS 10868) Change of Status Instrum CMS-10710 GenIC#11. (CMS 10868) Change of Status Instrument.docx	Form and Instruction
CMS-10710 GenIC#11. ICR Template_A11 Section 280 Clearance.docx CMS-10710 GenIC#11. ICR Template_A11 Section 280 Clearance	IC Document
CMS-10710 GenIC#11. MCSN_example to test.docx CMS-10710 GenIC#11. MCSN_example to test	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-10710.GenIC#11				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10710 GenIC#11. ICR Template_A11 Section 280 Clearance		07/09/2024
CMS-10710 GenIC#11. MCSN_example to test		07/09/2024

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

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