Requests for Mailed Disclosures

Transparency in Pricing Information (CMS-10715)

Documents and Forms

Document Name Document Type
CMS-10715 (Appendix 1) Transparency in Coverage Model Notice (clean)_10.07.24.docx Other-Instruction

Information Collection (IC) Details

IC Title:	Requests for Mailed Disclosures	Agency IC Tracking Number:	CCIIO - 10715

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.211(b)(2)(ii)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Instruction			CMS-10715 (Appendix 1) Transparency in Coverage Model Notice (clean)_10.07.24.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 836	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: 54 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	54,340	11,877	42,463
Annual IC Time Burden (Hours)	13,585	2,969	10,616
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.