Information Collection

Structuring and monitoring the CAP

IC 239116 under ICR 202506-0938-005 · OMB 0938-1390.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10662 Structuring and monitoring the CAP	Form and Instruction
Form CMS-10662 Notice_of_Corrective_Action_ Structuring and monitoring the CAP	Form and Instruction
Form CMS-10662 Corrective Action Follow-up Letter Structuring and monitoring the CAP	Form and Instruction
CMS-10662 Notice_of_Corrective_Action_ ASETT_Notice_of_Corrective_Action_2024_FINAL.docx	Form and Instruction
CMS-10662 Notice_of_Corrective_Action_ ASETT_Notice_of_Corrective_Action_2024_FINAL.docx	Form and Instruction
CMS-10662 Corrective Action Follow-up Letter ASETT_Follow_Up_Request_For_Information_Letter_CA_2024_FINAL.docx	Form and Instruction
CMS-10662 Corrective Action Follow-up Letter ASETT_Follow_Up_Request_For_Information_Letter_CA_2024_FINAL.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 160.308 45 CFR 160.310

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
Form and Instruction	CMS-10662				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10662				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	40	30	10
Annual IC Time Burden (Hours)	2,040	1,540	500
Annual IC Cost Burden (Dollars)	0	0	0

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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