Information Collection Request
ADA Dental Claim Form (CMS-10883)
ICR 202403-0938-016 · OMB 0938-1471 · Received in OIRA
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-10883 Paper Submission |
Form and Instruction | New | Available |
| Form CMS-10883 Electronic Submission |
Form and Instruction | New | Repair queued |
 CMS-10883.Supporting Statement Part A (3-28-24).docx |
Supporting Statement A | Uploaded 2024-03-29 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 266388 |  Paper Submission |
Form and Instruction | New | |
| 266385 | Electronic Submission |
Form and Instruction | New |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1471 |
| Type of Information Collection | New collection (Request for a new OMB Control Number) |
| Agency Tracking No | OIT |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |