Information Collection

Essential Community Provider and Network Adequacy Data Requirements

IC 251109 under ICR 202602-0938-012 · OMB 0938-1415.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10803 Appendix A Essential Community Provider and Network Adequacy Data Requirements	Form and Instruction
Form CMS-10803 Non-Network Plan Attestation - Questions Essential Community Provider and Network Adequacy Data Requirements	Form
CMS-10803 - Appendix C - Screenshots.pdf	Other-Screenshots
CMS-10803 Appendix A CMS-10803 - Appendix A - Template.pdf	Form and Instruction
CMS-10803 Non-Network Plan Attestation - Questions CMS-10803 - Appendix D - Attestation.pdf	Form

IC Title:

Agency IC Tracking Number:

CMS-10803

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.230 45 CFR 156.235

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10803	Yes	Yes	Paper Only
Other-Screenshots		Yes	No	Paper Only
Form	CMS-10803	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 164

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	164	-201	365
Annual IC Time Burden (Hours)	3,280	-916	4,196
Annual IC Cost Burden (Dollars)	142,245	-174,338	316,583

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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