Information Collection

Median Payer-Specific Negotiated Charge Data Worksheet

IC 276834 under ICR 202512-0938-006 · OMB 0938-1486.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10935 Median Payer-Specific Negotiated Charge Data Worksheet	Form
Form CMS-10935 Weighted Median MAO Payer-Specific Negotiated Charge Data Form Median Payer-Specific Negotiated Charge Data Worksheet	Form
Weighted Median MAO Payer-Specific Negotiated Charge Data Instructions.docx	Instruction
Weighted Median MAO Payer-Specific Negotiated Charge Data Instructions.docx	Instruction
CMS-10935 Weighted Median MAO Payer-Specific Negotiated Charge Dat Weighted Median MAO Payer-Specific Negotiated Charge Data Form.xlsx	Form
CMS-10935 Weighted Median MAO Payer-Specific Negotiated Charge Dat Weighted Median MAO Payer-Specific Negotiated Charge Data Form.xlsx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24(f)(4)(ii)

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	CMS-10935				Yes	Yes	Fillable Fileable
Instruction					Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,034

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,034	3,034
Annual IC Time Burden (Hours)	60,760	60,760
Annual IC Cost Burden (Dollars)	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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