Information Collection

Request Process

IC 249860 under ICR 202511-0938-015 · OMB 0938-1419.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10781 Request Process	Form and Instruction
Form CMS-10781 CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Compliant Request Process	Form and Instruction
CMS-10781 CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Co CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Compliant.pdf	Form and Instruction
CMS-10781 CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Co CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Compliant.pdf	Form and Instruction

IC Title:

Request Process

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 5.24 45 CFR 164.508 45 CFR 5.22 42 CFR 401.136

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-10781				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: HHS SORN 09-90-0058 Tracking Records and Case Files for FOIA and Privacy Act Requests and Appeals

FR Citation: 81 FR 17463

Number of Respondents: 22,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	22,600	3,600	19,000
Annual IC Time Burden (Hours)	7,533	1,200	6,333
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].