Information Collection

SSO Report of State Buy-in Problems

IC 221460 under ICR 202605-0938-017 · OMB 0938-0035.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1957 SSO Report of State Buy-In Problem (email-based template and instructions) SSO Report of State Buy-in Problems	Form and Instruction
CMS-1957 SSO Report of State Buy-In Problem (email-based template CMS-1957 Email-Based Buy-in Reporting_04152026.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

CMS-1957

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 407.40

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-1957				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	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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