Information Collection

Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form

IC 223444 under ICR 202606-0938-005 · OMB 0938-0948.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS10148 HIPAA Non-privacy complaint form Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	Form and Instruction
Form CMS10148 HIPAA Non-privacy complaint form Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form	Form and Instruction
CMS10148 HIPAA Non-privacy complaint form CMS10148Clean.docx	Form and Instruction
CMS10148 HIPAA Non-privacy complaint form CMS10148Clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

OHEI

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	CMS10148				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Program Information Management System (PIMS)

FR Citation: 75 FR 18841

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	18,256	18,256

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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