Information Collection

Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

IC 46152 under ICR 202602-0938-003 · OMB 0938-1013.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10198 Creditable Coverage Disclosure to CMS Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction
Form CMS-10198 CC Form (screen shot) Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots.docx	Form and Instruction
CMS-10198 CC Form (screen shot) CCOnlinePageView.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56e

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-10198				Yes	Yes	Fillable Printable
Form	CMS-10198				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 134,237

Number of Respondents for Small Entity: 8,000

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	134,237	-7,049	141,286
Annual IC Time Burden (Hours)	11,142	-632	11,774
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].