Information Collection

Preparation and Issuance of Model Notices (section 423.120(c)(6))

IC 231341 under ICR 202412-0938-003 · OMB 0938-0964.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10141 Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction
Form CMS-10141 Model Precluded Provider Letter Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction
CMS-10141 Model Precluded Provider Letter Attachment 2. Part C and D Model Precluded Provider Letter.pdf	Form and Instruction
CMS-10141 Model Precluded Provider Letter Attachment 2. Part C and D Model Precluded Provider Letter.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.120(c)(6)

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-10141				Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	15,000	15,000
Annual IC Time Burden (Hours)	1,245	1,245
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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