OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

DE Entity Operational Readiness Review (ORR)

IC 263264 under ICR 202404-0938-015 · OMB 0938-1463.

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Information Collection (IC) Details

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DE Entity Operational Readiness Review (ORR) CCIIO - 10877
 
No Modified
 
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 Appendix_E_DEE-Documentation-Package_v1.7_508.pdf Yes No Paper Only
Form and Instruction CMS-10877 Privacy Questiionaire Appendix_F_EDE-Privacy-Questionnaire_08.02.22_508.pdf Yes Yes Fillable Fileable
Instruction Appendix_G_API-Functional-Integration-Toolkit_03.31.23_508.pdf Yes No Paper Only
Form and Instruction CMS-10877 Application User Interface Toolkit Appendix_H_Application-UI-Toolkit_v3.1_03.31.23_508.pdf Yes No Fillable Printable
Form and Instruction CMS-10877 Communications Toolkit Appendix_J_EDE-Business-Audit-Instructions-Report-Template_PY2024_508.pdf Yes Yes Paper Only
Form and Instruction CMS-10877 Eligibility Results Toolkit Appendix_K_EDE-Eligibility-Results-Toolkit-Phase1_PY2023_Final_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 Eligibility Results Toolkit - Phase 2 Appendix_L_EDE-Eligibility-Results-Toolkit-Phase2_PY2023_Final_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 Eligibility Results Toolkit - Phase 3 Appendix_M_EDE-Eligibility-Results-Toolkit-Phase3_PY2023_Final_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 Change Notification Form Appendix_N_EDE-Entity-Initiated-Change-Notification-Form_v2_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10877 Business Agreement BY 2024 Appendix_O_EDE_Business_Agreement_PY_2024_Final_508.pdf Yes Yes Fillable Fileable
Form CMS-10877 INTERCONNECTION SECURITY AGREEMENT Appendix_Q_CMS-EDE-ISA-Template_v3.4_Final_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 EDE Communication Toolkit Appendix_I_EDE-Communications-Toolkit_03.10.23_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10877 SAP Template Appendix_P_NEE-EDE-SAP-Template_v3.1_Final_02.24.22_508.pdf Yes No Fillable Fileable

Health Health Care Services

 

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