Information Collection

§495.24(e) Objectives/Measures (hospitals/CAHs)

IC 216082 under ICR 202605-0938-014 · OMB 0938-1278.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form cms-10552 Medicare Promoting Interoperability Program Hardship Exception Application §495.24(e) Objectives/Measures (hospitals/CAHs)	Form and Instruction
PI_CY2025_HQR_UG_121825.pdf	Instruction
cms-10552 Medicare Promoting Interoperability Program Hardship Exc PI Hardship Exception Application_(05-04-2026).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 495.24

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
Instruction					Yes	Yes	Fillable Fileable
Form and Instruction	cms-10552				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,550

Number of Respondents for Small Entity: 2,331

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	4,550	0	4,550
Annual IC Time Burden (Hours)	30,378	227	30,151
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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