Request Process

FOIA/Privacy Act Requests for Medicare Claims Data via CMS FOIA Public Portal (CMS-10781)

Documents and Forms

Document Name Document Type
Form CMS-10781 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

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10781	CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Compliant	CMS-10781.Screenshots for FOIA Beneficiary Portal 508 Compliant.pdf		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 %

	Requested	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

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.