CMS-10803 - Appendix_C_ECP_Screenshotsf

OMB control number: 0938-1415 Expiration Date: XX/XX/20XX

ECP Screenshots

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1415. This information collection requires QHP issuers, including SADP issuers, to ensure access to a sufficient number and geographic distribution of essential community providers (ECPs), where available, that serve predominantly low-income, medically underserved individuals. The time required to complete this information collection is estimated to average less than 1,458 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory under 2702(c) of the Public Health Service Act and will be kept private in accordance with regulations at 45 CFR 155.260, Privacy and Security of Personally Identifiable Information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 and [email protected], Attention: Information Collections Clearance Officer.