Information Collection

Forms used to update the DUA Information

IC 253069 under ICR 202505-0938-012 · OMB 0938-0734.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-235 Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 DUA Certificate of Disposition Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 QE DUA Signature Addendum Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 NDTR DUA Signature Addendum Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 Contractor DUA Signature Addendum Forms used to update the DUA Information	Form and Instruction
CMS-R-235 DUA Certificate of Disposition RIF COD_508.docx	Form and Instruction
CMS-R-235 DUA Certificate of Disposition RIF COD_508.docx	Form and Instruction
CMS-R-235 QE DUA Signature Addendum QE DUA Signature Addendum_.docx	Form and Instruction
CMS-R-235 QE DUA Signature Addendum QE DUA Signature Addendum_.docx	Form and Instruction
CMS-R-235 NDTR DUA Signature Addendum NDTR DUA Signature Addendum.docx	Form and Instruction
CMS-R-235 NDTR DUA Signature Addendum NDTR DUA Signature Addendum.docx	Form and Instruction
CMS-R-235 Contractor DUA Signature Addendum Contractor DUA Signature Addendum_.docx	Form and Instruction
CMS-R-235 Contractor DUA Signature Addendum Contractor DUA Signature Addendum_.docx	Form and Instruction
RIF-COD REDLINE.pdf Track Change - RIF COD	IC Document
RIF-COD REDLINE.pdf Track Change - RIF COD	IC Document
RIF COD_JobAid.pdf RIF COD_JobAid	IC Document
RIF COD_JobAid.pdf RIF COD_JobAid	IC Document
Contractor Signature Addendum_JobAid.pdf Contractor Signature Addendum_JobAid	IC Document
Contractor Signature Addendum_JobAid.pdf Contractor Signature Addendum_JobAid	IC Document
QE Signature Addendum_JobAid.pdf QE Signature Addendum_JobAid	IC Document
QE Signature Addendum_JobAid.pdf QE Signature Addendum_JobAid	IC Document
NDTR Signature Addendum_JobAid.pdf NDTR Signature Addendum_JobAid	IC Document
NDTR Signature Addendum_JobAid.pdf NDTR Signature Addendum_JobAid	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Forms used to update the DUA Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	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: 2,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,800	-2,800	5,600
Annual IC Time Burden (Hours)	476	-476	952
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - RIF COD		05/27/2025
RIF COD_JobAid		05/28/2025
Contractor Signature Addendum_JobAid		05/28/2025
QE Signature Addendum_JobAid		05/28/2025
NDTR Signature Addendum_JobAid		05/28/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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