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Information Collection

Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form

IC 223444 under ICR 202509-0938-028 · OMB 0938-0948.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10148 HIPAA ADMINISTRATIVE SIMPLIFICATION (NON-PRIVACY/SECURITY) COMPLAINT FORM CMS-10148 Form.docx Yes Yes Fillable Fileable

Health Health Care Services

Program Information Management System (PIMS)  75 FR 18841

400 0
   
Individuals or Households
 
   80 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 400 0 379 0 21 0
Annual IC Time Burden (Hours) 400 0 379 0 21 0
Annual IC Cost Burden (Dollars) 18,256 0 18,256 0 0 0

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