Information Collection

Monitoring and appeals process for survey vendors

IC 212011 under ICR 202508-0938-006 · OMB 0938-1249.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10520 Monitoring and appeals process for survey vendors	Form and Instruction
Form CMS-10520 Vendor Appeal Form Monitoring and appeals process for survey vendors	Form and Instruction
CMS-10520 Vendor Appeal Form CMS-10520 - QHP Survey - Request for Appeal Form.docx	Form and Instruction
CMS-10520 Vendor Appeal Form CMS-10520 - QHP Survey - Request for Appeal Form.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 156.200(b)(5) 45 CFR 156.1105 45 CFR 155.200(d) 45 CFR 156.1120-1125

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-10520				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

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: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6	-8	14
Annual IC Time Burden (Hours)	6	-8	14
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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