Information Collection

Burden on Individuals and States

IC 272707 under ICR 202411-0938-013 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MLI for Interpreter Services FINAL.pdf	Other-Medicare Advantage Multi-Langu
MLI for Interpreter Services FINAL.pdf	Other-Medicare Advantage Multi-Langu
CMS-10891 Application for Medicare Savings Programs (MSP) (English FINAL_MSP Model Form_100824.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (English MSP Model application clean 1.15.25.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Hindi) MSP Model Form_110624_Hindi.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Hindi) Placeholder Hindi.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Arabic) MSP Model Form_11062024_Arabic.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Arabic) Placeholder Arabic.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (French MSP Model Form_11062024_French Creole.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (French Placeholder French Creole.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (French) MSP Model Form_11062024_French.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (French) Placeholder French.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (German) MSP Model Form_11062024_German.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (German) Placeholder German.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Italian MSP Model Form_11062024_Italian.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Italian Placeholder Italian.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Japanes MSP Model Form_11062024_Japanese.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Japanes Placeholder Japanese.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Korean) MSP Model Form_11062024_Korean.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Korean) Placeholder Korean.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Polish) MSP Model Form_11062024_Polish.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Polish) Placeholder Polish.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Portugu MSP Model Form_11062024_Portuguese.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Portugu Placeholder Portuguese.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Russian MSP Model Form_11062024_Russian.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Russian Placeholder Russian.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Simplif MSP Model Form_11062024_Simplified Chinese.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Simplif Placeholder Simplified Chinese.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Spanish MSP Model Form_11062024_Spanish.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Spanish Placeholder Spanish.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Tagalog MSP Model Form_11062024_Tagalog.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Tagalog Placeholder Tagalog.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Traditi MSP Model Form_11062024_Traditional Chinese.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Traditi Placeholder Traditional Chinese.docx	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Vietnam MSP Model Form_11062024_Vietnamese.pdf	Form and Instruction
CMS-10891 Application for Medicare Savings Programs (MSP) (Vietnam Placeholder Vietnamese.docx	Form and Instruction
REDLINE_MSP Model Form_092424.pdf REDLINE: Application for Medicare Savings Programs (MSP) (English)	IC Document
Summary of changes to MSP model form.pdf Summary of Changes: Application for Medicare Savings Programs (MSP)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Burden on Individuals and States

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Medicare Advantage Multi-Language Insert (MLI)			MLI for Interpreter Services FINAL.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (English)	MSP Model application clean 1.15.25.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Hindi)	Placeholder Hindi.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Arabic)	Placeholder Arabic.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (French Creole)	Placeholder French Creole.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (French)	Placeholder French.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (German)	Placeholder German.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Italian)	Placeholder Italian.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Japanese)	Placeholder Japanese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Korean)	Placeholder Korean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Polish)	Placeholder Polish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Portuguese)	Placeholder Portuguese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Russian)	Placeholder Russian.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Simplified Chinese)	Placeholder Simplified Chinese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Spanish)	Placeholder Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Tagalog)	Placeholder Tagalog.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Traditional Chinese)	Placeholder Traditional Chinese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10891	Application for Medicare Savings Programs (MSP) (Vietnamese)	Placeholder Vietnamese.docx	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: 3,460,750

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,460,750	3,460,750
Annual IC Time Burden (Hours)	5,517,157	5,517,157
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.