Information Collection

Conducting CMRs with the standardized format and Fulfillment burden

IC 199672 under ICR 202501-0938-008 · OMB 0938-1154.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf	Instruction
MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf	Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.153(d)(1)(vii)(D) 42 CFR 423.153(d)(1)(vii)(B)

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
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,639,526

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,639,526	962,241	4,677,285
Annual IC Time Burden (Hours)	3,759,872	641,526	3,118,346
Annual IC Cost Burden (Dollars)	5,763,596	983,411	4,780,185

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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