Document Name Document Type
Form CMS-10662 Compliance Review Form and Instruction
CMS-10662 Operating_Rule_Response_Attestation ASHEPS_Operating_Rule_Response_Attestation_2024_FINAL_CLEAN.docx Form and Instruction
CMS-10662 Compliance_Review_Package ASHEPS_Compliance_Review_Package_2024_FINAL_CLEAN.docx Form and Instruction
CMS-10662 Compliance Review Program Triage Questionnaire Clearingh ASETT_Compliance_Review_Triage_Questionnare_CLH_2024_FINAL.docx Form and Instruction
CMS-10662 Compliance Review Program Triage Questionnaire Health Pl ASETT_Compliance_Review_Triage_Questionnare_HPL_2024_FINAL.docx Form and Instruction
CMS-10662 Compliance Review Program Triage Questionnaire Providers ASETT_Compliance_Review_Triage_Questionnare_PRO_2024_FINAL.docx Form and Instruction
ASETT_cms 10662_Operating_Rule_Response_Attestation_FINAL_2024_Track_Changes.docx Track Change - Operating_Rule_Response_Attestation IC Document
ASETT_CMS 10662_ Notice of Compliance Review_2023_FINAL_Track_Changes.docx Track Change - Compliance_Review_Package IC Document
ASETT_Notice_of_Draft_Findings_2024_FINAL.docx Assessment_Draft_Findings_Report IC Document
ASETT_Notice_of_Compliance_Review_Closure_CA_Completed_2024_FINAL.docx Notice of Compliance Review Closure IC Document
ASETT_Notice_of_CR_Closure_No_Violations_2024_FINAL.docx Notice_of_CR_Closure_No_Violations IC Document
ASETT_Follow_Up_Request_For_Information_Letter_2024_FINAL.docx Follow_Up_Request_For_Information IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Compliance Review	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 160.310 45 CFR 160.308

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10662	Operating_Rule_Response_Attestation	ASHEPS_Operating_Rule_Response_Attestation_2024_FINAL_CLEAN.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10662	Compliance_Review_Package	ASHEPS_Compliance_Review_Package_2024_FINAL_CLEAN.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10662	Compliance Review Program Triage Questionnaire Clearinghouses	ASETT_Compliance_Review_Triage_Questionnare_CLH_2024_FINAL.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10662	Compliance Review Program Triage Questionnaire Health Plans	ASETT_Compliance_Review_Triage_Questionnare_HPL_2024_FINAL.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10662	Compliance Review Program Triage Questionnaire Providers	ASETT_Compliance_Review_Triage_Questionnare_PRO_2024_FINAL.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	50	50
Annual IC Time Burden (Hours)	1,000	500	500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change - Operating_Rule_Response_Attestation	ASETT_cms 10662_Operating_Rule_Response_Attestation_FINAL_2024_Track_Changes.docx	06/06/2025
Track Change - Compliance_Review_Package	ASETT_CMS 10662_ Notice of Compliance Review_2023_FINAL_Track_Changes.docx	06/06/2025
Assessment_Draft_Findings_Report	ASETT_Notice_of_Draft_Findings_2024_FINAL.docx	06/06/2025
Notice of Compliance Review Closure	ASETT_Notice_of_Compliance_Review_Closure_CA_Completed_2024_FINAL.docx	06/06/2025
Notice_of_CR_Closure_No_Violations	ASETT_Notice_of_CR_Closure_No_Violations_2024_FINAL.docx	06/06/2025
Follow_Up_Request_For_Information	ASETT_Follow_Up_Request_For_Information_Letter_2024_FINAL.docx	06/06/2025

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

Compliance Review