Information Collection

Disclosure Request Form

IC 229441 under ICR 202408-0938-032 · OMB 0938-1080.

Documents and Forms

Document Name Document Type
Form CMS-10307 Disclosure Request Form Form and Instruction
CMS-10307 Model Disclosure Template (English) CMS-10307_Model_Disclosure_Template_ENGLISH.pdf Form and Instruction
CMS-10307 Model Disclosure Template (English) CMS-10307_Model_Disclosure_Template_ENGLISH.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Arabic) CMS-10307_Model_Disclosure_Template_ARABIC.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Arabic) CMS-10307_Model_Disclosure_Template_ARABIC.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Korean_ CMS-10307_Model_Disclosure_Template_FRENCH.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Korean_ CMS-10307_Model_Disclosure_Template_FRENCH.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Tagalog) CMS-10307_Model_Disclosure_Template_TAGALOG.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Tagalog) CMS-10307_Model_Disclosure_Template_TAGALOG.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Spanish) CMS-10307_Model_Disclosure_Template_SPANISH.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Spanish) CMS-10307_Model_Disclosure_Template_SPANISH.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Vietnamese) CMS-10307_Model_Disclosure_Template_VIETNAMESE.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Vietnamese) CMS-10307_Model_Disclosure_Template_VIETNAMESE.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Chinese) CMS-10307_Model_Disclosure_Template_TCHINESE.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Chinese) CMS-10307_Model_Disclosure_Template_TCHINESE.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Vietnamese) CMS-10307_Model_Disclosure_Template_VIETNAMESE.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Vietnamese) CMS-10307_Model_Disclosure_Template_VIETNAMESE.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Korean)) CMS-10307_Model_Disclosure_Template_KOREAN.pdf Form and Instruction
CMS-10307 Model Disclosure Template (Korean)) CMS-10307_Model_Disclosure_Template_KOREAN.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disclosure Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 146.136(d)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10307	Model Disclosure Template (English)	CMS-10307_Model_Disclosure_Template_ENGLISH.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Arabic)	CMS-10307_Model_Disclosure_Template_ARABIC.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Korean_	CMS-10307_Model_Disclosure_Template_FRENCH.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Tagalog)	CMS-10307_Model_Disclosure_Template_TAGALOG.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Spanish)	CMS-10307_Model_Disclosure_Template_SPANISH.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Vietnamese)	CMS-10307_Model_Disclosure_Template_VIETNAMESE.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Chinese)	CMS-10307_Model_Disclosure_Template_TCHINESE.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Vietnamese)	CMS-10307_Model_Disclosure_Template_VIETNAMESE.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10307	Model Disclosure Template (Korean))	CMS-10307_Model_Disclosure_Template_KOREAN.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 191,385	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	191,385	23,960	167,425
Annual IC Time Burden (Hours)	15,949	1,997	13,952
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.