Information Collection

RIF Request Packet

IC 8408 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 RIF Request Packet	Form and Instruction
Form CMS-R-235 RIF Request Application RIF Request Packet	Form and Instruction
Form CMS-R-235 State Agency Supplement RIF Request Packet	Form and Instruction
Form CMS-R-235 Innovator Supplement RIF Request Packet	Form and Instruction
Form CMS-R-235 Collaborator Supplement RIF Request Packet	Form and Instruction
Form CMS-R-235 Key Personnel Supplement RIF Request Packet	Form and Instruction
Form CMS-R-235 Amendment Request Form RIF Request Packet	Form and Instruction
Form CMS-R-235 RIF Extenstion Request Form RIF Request Packet	Form and Instruction
Form CMS-R-235 RIF DUA Signature Addendum RIF Request Packet	Form and Instruction
CMS-R-235 RIF Request Application Attachment A - RIF Request Application .docx	Form and Instruction
CMS-R-235 RIF Request Application Attachment A - RIF Request Application .docx	Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf	Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf	Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf	Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf	Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf	Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx	Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx	Form and Instruction
CMS-R-235 RIF Extenstion Request Form RIF Extenstion Request Form.docx	Form and Instruction
CMS-R-235 RIF Extenstion Request Form RIF Extenstion Request Form.docx	Form and Instruction
CMS-R-235 RIF DUA Signature Addendum RIF DUA Signature Addendum.docx	Form and Instruction
CMS-R-235 RIF DUA Signature Addendum RIF DUA Signature Addendum.docx	Form and Instruction
Attachment A - RIF Application REDLINE.pdf Track Change - RIF Application	IC Document
Attachment A - RIF Application REDLINE.pdf Track Change - RIF Application	IC Document
RIF-Amendment REDLINE.pdf Track Change - RIF Amendment	IC Document
RIF-Amendment REDLINE.pdf Track Change - RIF Amendment	IC Document
RIF Amendment_JobAid.pdf RIF Amendment_JobAid	IC Document
RIF Amendment_JobAid.pdf RIF Amendment_JobAid	IC Document
RIF Attachment A_JobAid.pdf RIF Application_JobAid	IC Document
RIF Attachment A_JobAid.pdf RIF Application_JobAid	IC Document
RIF Extension Request_JobAid.pdf RIF Extension Request_JobAid	IC Document
RIF Extension Request_JobAid.pdf RIF Extension Request_JobAid	IC Document
RIF Signature Addendum_JobAid.pdf RIF Signature Addendum_JobAid	IC Document
RIF Signature Addendum_JobAid.pdf RIF Signature Addendum_JobAid	IC Document
Form Fields .docx IT system - Data collection fields	IC Document
Form Fields .docx IT system - Data collection fields	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

RIF Request Packet

Agency IC Tracking Number:

CMS-R-235

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
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: 3,455

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	3,455	750	2,705
Annual IC Time Burden (Hours)	1,624	375	1,249
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - RIF Application		05/27/2025
Track Change - RIF Amendment		05/27/2025
RIF Amendment_JobAid		05/27/2025
RIF Application_JobAid		05/27/2025
RIF Extension Request_JobAid		05/27/2025
RIF Signature Addendum_JobAid		05/27/2025
IT system - Data collection fields		05/29/2025

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

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