Information Collection

Required Disclosures to Participants, Beneficiaries, or Enrollees - (One-time)

IC 249943 under ICR 202610-0938-007 · OMB 0938-1429.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10715 Transparency in Coverage Model Notice Required Disclosures to Participants, Beneficiaries, or Enrollees - (One-time)	Form
CMS-10715 Transparency in Coverage Model Notice CMS-10715 - Appendix 1 - Transparency in Coverage Model Notice.docx	Form

IC Title:

Agency IC Tracking Number:

CCIIO - 10715

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.211(b)

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	CMS-10715				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 790

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 54 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	790	-41,673	42,463
Annual IC Time Burden (Hours)	7,174,413	7,163,797	10,616
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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