Information Collection

SBC Disclosure

IC 199007 under ICR 202412-0938-010 · OMB 0938-1146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1146 can be found here:

2025-04-10 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10407 SBC Template SBC Disclosure	Form
Maternity-Care-Narrative-05-05-22.pdf	Other-Maternity Care Narrative
Maternity-Care-Narrative-05-05-22.pdf	Other-Maternity Care Narrative
SBC_Diabetes-Narrative-051222 508.pdf	Other-Diabetes 2 Narrative
SBC_Diabetes-Narrative-051222 508.pdf	Other-Diabetes 2 Narrative
Uniform-Glossary-051222 508.pdf	Other-Uniform Glossary Anchor
Uniform-Glossary-051222 508.pdf	Other-Uniform Glossary Anchor
English_Why This Matters NO Answers_Final_11.01.24 (clean).docx	Other-What the Plan Covers and What
English_Why This Matters NO Answers_Final_11.01.24 (clean).docx	Other-What the Plan Covers and What
English_Why This Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters for SBC (Yes
English_Why This Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters for SBC (Yes
Group-Instructions-051222 508.pdf	Instruction
Group-Instructions-051222 508.pdf	Instruction
Individual-Instructions-051222 508.pdf	Instruction
Individual-Instructions-051222 508.pdf	Instruction
English_Sample-Completed-SBC-Accessible-Format_Final_11.01.24 (clean).docx	Other-Completed SBC Template
English_Sample-Completed-SBC-Accessible-Format_Final_11.01.24 (clean).docx	Other-Completed SBC Template
English_Sample-Completed-SBC-Accessible-Format_Final_11.01.24 (clean).docx	Other-SBC Template
English_Sample-Completed-SBC-Accessible-Format_Final_11.01.24 (clean).docx	Other-SBC Template
Foot-Fracture-Narrative-051222 508.pdf	Other-Foot Fracture Narrative
Foot-Fracture-Narrative-051222 508.pdf	Other-Foot Fracture Narrative
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Instruction
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Instruction
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Other-Coverage Calculator
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Other-Coverage Calculator
Having-a-Baby-Guide-051222 508.pdf	Other-Template
Having-a-Baby-Guide-051222 508.pdf	Other-Template
Managing-Type-2-Diabetes-Guide-051222 508.pdf	Other-Diabetes Guide
Managing-Type-2-Diabetes-Guide-051222 508.pdf	Other-Diabetes Guide
Uniform-Glossary-051222 508.pdf	Other-Glossary Anchor
Uniform-Glossary-051222 508.pdf	Other-Glossary Anchor
Simple-Fracture-Guide-051222 508.pdf	Other-Template
Simple-Fracture-Guide-051222 508.pdf	Other-Template
English_AIAN-Limited-Cost-Sharing_Final_11.01.24 (clean).docx	Instruction
English_AIAN-Limited-Cost-Sharing_Final_11.01.24 (clean).docx	Instruction
English_AIAN-Zero-Cost-Sharing_Final_11.01.24 (clean).docx	Instruction
English_AIAN-Zero-Cost-Sharing_Final_11.01.24 (clean).docx	Instruction
English_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary
English_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary
Carolinian_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Carolinian
Carolinian_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Carolinian
Carolinian_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Carolinian
Carolinian_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Carolinian
Carolinian_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters NO Answers -
Carolinian_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters NO Answers -
Carolinian_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters - Yes Answers
Carolinian_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters - Yes Answers
Chamorro_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Chamorro
Chamorro_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Chamorro
Chamorro_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform glossary - Chamorro
Chamorro_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform glossary - Chamorro
Chamorro_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Chamorro_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Chamorro_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters YES Answers -
Chamorro_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters YES Answers -
Chinese_SBC-Template-Accessible-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Chinese
Chinese_SBC-Template-Accessible-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Chinese
Chinese_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Chinese
Chinese_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Chinese
Chinese_Why This Matters No Answers_Final_11.01.24 (clean).docx	Other-Why This Matters NO Answers -
Chinese_Why This Matters No Answers_Final_11.01.24 (clean).docx	Other-Why This Matters NO Answers -
Chinese_Why This Matters Yes Answers_Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Chinese_Why This Matters Yes Answers_Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Pennsylvania Dutch_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Pennsylvania Du
Pennsylvania Dutch_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Pennsylvania Du
Pennsylvania Dutch_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Pennsylvani
Pennsylvania Dutch_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Pennsylvani
Pennsylvania Dutch_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Pennsylvania Dutch_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Pennsylvania Dutch_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters YES Answers -
Pennsylvania Dutch_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters YES Answers -
Samoan_SBC Template Standard Format_Final_11.01.24 (clean).docx	Other-SBC Template - Samoan
Samoan_SBC Template Standard Format_Final_11.01.24 (clean).docx	Other-SBC Template - Samoan
Samoan_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Samoan
Samoan_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Samoan
Samoan_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Samoan_Why this Matters NO Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Samoan_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers
Samoan_Why this Matters YES Answers_Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers
Spanish_SBC-Template-Accessible-Format__Final_11.01.24 (clean).docx	Other-SBC Template - Spanish
Spanish_SBC-Template-Accessible-Format__Final_11.01.24 (clean).docx	Other-SBC Template - Spanish
Spanish_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Spanish
Spanish_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Spanish
Spanish_Why This Matters No Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Spanish_Why This Matters No Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Tagalog_SBC-Template-Accessible-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Tagalog
Tagalog_SBC-Template-Accessible-Format_Final_11.01.24 (clean).docx	Other-SBC Template - Tagalog
Tagalog_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Tagalog
Tagalog_Uniform Glossary_Final_11.01.24 (clean).docx	Other-Uniform Glossary - Tagalog
Tagalog_Why This Matters No Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Tagalog_Why This Matters No Answers_Final_11.01.24 (clean).docx	Other-Why This Matters No Answers -
Tagalog_Why This Matters Yes Answers_Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
Tagalog_Why This Matters Yes Answers_Final_11.01.24 (clean).docx	Other-Why This Matters Yes Answers -
CMS-10407 SBC Template SBC-Template-Accessible-Format.pdf	Form
CMS-10407 SBC Template SBC-Template-Accessible-Format.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

SBC Disclosure

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Maternity Care Narrative		Yes	No	Printable Only
Other-Diabetes 2 Narrative		Yes	No	Printable Only
Other-Uniform Glossary Anchor		Yes	No	Printable Only
Other-What the Plan Covers and What You Pay (No Answers)		Yes	No	Printable Only
Other-Why This Matters for SBC (Yes Answers)		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Other-Completed SBC Template		Yes	No	Fillable Fileable
Other-SBC Template		Yes	No	Fillable Fileable
Other-Foot Fracture Narrative		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Other-Coverage Calculator		Yes	No	Fillable Printable
Other-Template		Yes	No	Printable Only
Other-Diabetes Guide		Yes	No	Printable Only
Other-Glossary Anchor		Yes	No	Printable Only
Other-Template		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Other-Uniform Glossary		Yes	No	Printable Only
Form	CMS-10407	Yes	Yes	Fillable Fileable
Other-SBC Template - Carolinian		Yes	No	Printable Only
Other-Uniform Glossary - Carolinian		Yes	No	Printable Only
Other-Why This Matters NO Answers - Carolinian		Yes	No	Printable Only
Other-Why This Matters - Yes Answers - Carolinian		Yes	No	Printable Only
Other-SBC Template - Chamorro		Yes	No	Printable Only
Other-Uniform glossary - Chamorro		Yes	No	Printable Only
Other-Why This Matters No Answers - Chamorro		Yes	No	Printable Only
Other-Why This Matters YES Answers - Chamorro		Yes	No	Printable Only
Other-SBC Template - Chinese		Yes	No	Printable Only
Other-Uniform Glossary - Chinese		Yes	No	Printable Only
Other-Why This Matters NO Answers - Chinese		Yes	No	Printable Only
Other-Why This Matters Yes Answers - Chinese		Yes	No	Printable Only
Other-SBC Template - Pennsylvania Dutch		Yes	No	Printable Only
Other-Uniform Glossary - Pennsylvania Dutch		Yes	No	Printable Only
Other-Why This Matters No Answers - Pennsylvania Dutch		Yes	No	Printable Only
Other-Why This Matters YES Answers - Pennsylvania Dutch		Yes	No	Printable Only
Other-SBC Template - Samoan		Yes	No	Printable Only
Other-Uniform Glossary - Samoan		Yes	No	Printable Only
Other-Why This Matters No Answers - Samoan		Yes	No	Printable Only
Other-Why This Matters Yes Answers		Yes	No	Printable Only
Other-SBC Template - Spanish		Yes	No	Printable Only
Other-Uniform Glossary - Spanish		Yes	No	Printable Only
Other-Why This Matters No Answers - Spanish		Yes	No	Printable Only
Other-Why This Matters Yes Answers - Spanish		Yes	No	Printable Only
Other-Why This Matters Yes Answers - Spanish		Yes	No	Printable Only
Other-SBC Template - Tagalog		Yes	No	Printable Only
Other-Uniform Glossary - Tagalog		Yes	No	Printable Only
Other-Why This Matters No Answers - Tagalog		Yes	No	Printable Only
Other-Why This Matters Yes Answers - Tagalog		Yes	No	Printable Only

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: 679

Number of Respondents for Small Entity: 35

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	24,211,211	24,211,211
Annual IC Time Burden (Hours)	203,564	203,564
Annual IC Cost Burden (Dollars)	10,494,154	10,494,154

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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