Information Collection

Reporting Appeals and Grievance Data

IC 46763 under ICR 202605-0938-006 · OMB 0938-0778.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-R-0282 Data Form_2026_clean_.docx	Other-Sample Report
CMS-R-0282_Data Form Instructions_2026_.docx	Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.111(c)(3)

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
Other-Sample Report					Yes	No	Printable Only
Instruction					Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 932

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: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	66,500	3,700	62,800
Annual IC Time Burden (Hours)	5,320	296	5,024
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.

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