Information Collection

Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

IC 46152 under ICR 202507-0938-007 · OMB 0938-1013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10198 Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
Form CMS-10198 Creditable Coverage Disclosure to CMS Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
Form CMS-10198 CC Form (screen shot) Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots.docx Form and Instruction
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots.docx Form and Instruction
CMS-10198 CC Form (screen shot) CCOnlinePageView.pdf Form
CMS-10198 CC Form (screen shot) CCOnlinePageView.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56e

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198	Creditable Coverage Disclosure to CMS	CC Disclosure to CMS Instructions and Screen Shots.docx		Yes	Yes	Fillable Printable
Form	CMS-10198	CC Form (screen shot)	CCOnlinePageView.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 141,286	Number of Respondents for Small Entity: 8,000

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	141,286	38,309	102,977
Annual IC Time Burden (Hours)	11,774	3,193	8,581
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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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