Information Collection

Required Disclosures to Participants, Beneficiaries, or Enrollees - (One-time)

IC 249943 under ICR 202601-0938-002 · OMB 0938-1429.

Documents and Forms

Document Name Document Type
Form CMS-10715 Transparency in Coverage Model Notice Required Disclosures to Participants, Beneficiaries, or Enrollees - (One-time) Form
CMS-10715 Transparency in Coverage Model Notice CMS-10715 (Appendix 1) Transparency in Coverage Model Notice 508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Required Disclosures to Participants, Beneficiaries, or Enrollees - (One-time)	Agency IC Tracking Number:	CCIIO - 10715

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.211(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10715	Transparency in Coverage Model Notice	CMS-10715 (Appendix 1) Transparency in Coverage Model Notice 508.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 790	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: 54 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	790	-41,673	42,463
Annual IC Time Burden (Hours)	7,174,413	7,163,797	10,616
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.

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