Information Collection

Internet-based Self-Service Tool

IC 249942 under ICR 202410-0938-006 · OMB 0938-1429.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1429 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10715 Internet-based Self-Service Tool	Form and Instruction
Form CMS-10715 In-network Rate Machine-Readable File Data Elements Internet-based Self-Service Tool	Form and Instruction
Form CMS-10715 APPENDIX 3: The Allowed Amount Machine-Readable File Data Elements Internet-based Self-Service Tool	Form and Instruction
CMS-10715 In-network Rate Machine-Readable File Data Elements CMS-10715-Transparency in Coverage_Appendix 2_Final .pdf	Form and Instruction
CMS-10715 In-network Rate Machine-Readable File Data Elements CMS-10715-Transparency in Coverage_Appendix 2_Final .pdf	Form and Instruction
CMS-10715 APPENDIX 3: The Allowed Amount Machine-Readable File Dat CMS-10715-Transparency in Coverage_Appendix 3_.pdf	Form and Instruction
CMS-10715 APPENDIX 3: The Allowed Amount Machine-Readable File Dat CMS-10715-Transparency in Coverage_Appendix 3_.pdf	Form and Instruction

IC Title:

Internet-based Self-Service Tool

Agency IC Tracking Number:

CCIIO-10715

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.210(b)(2)(i)

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
Form and Instruction	CMS-10715				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10715				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 980

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	980	980
Annual IC Time Burden (Hours)	22,835,410	22,835,410
Annual IC Cost Burden (Dollars)	0	0

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.

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