Information Collection

Conducting CMRs with the standardized format and Fulfillment burden

IC 199672 under ICR 202403-0938-008 · OMB 0938-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf	Instruction
MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf	Instruction

IC Title:

Conducting CMRs with the standardized format and Fulfillment burden

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.153(d)(1)(vii)(D) 42 CFR 423.153(d)(1)(vii)(B)

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
Instruction			MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 849

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,382,774	-4,181	2,386,955
Annual IC Time Burden (Hours)	1,588,595	-2,788	1,591,383
Annual IC Cost Burden (Dollars)	1,829,970	-389,898	2,219,868

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.