Information Collection

AV Continuance Tables

IC 230941 under ICR 202512-0938-018 · OMB 0938-1353.

Documents and Forms

Document Name Document Type
CMS-10637 Appendix A_AV Continuance Tables_508.pdf Other-Template

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	AV Continuance Tables	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.135

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Template			CMS-10637 Appendix A_AV Continuance Tables_508.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	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 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	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.

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