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

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

Information Collection (IC) Details

View Information Collection (IC)

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

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198	Creditable Coverage Disclosure to CMS	CC Disclosure to CMS Instructions and Screen Shots.docx		Yes	Yes	Fillable Printable
Form	CMS-10198	CC Form (screen shot)	CCOnlinePageView.pdf		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 %

	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

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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