OMB control number
Letter Requesting Waiver of Medicare/Medicaid Enrollment Application Fee; Submission of Fingerprints; Submission of Medicaid Identifying Information; Medicaid Site Visit and Rescreening (CMS-10357)
OMB 0938-1137 · HHS/CMS.
OMB 0938-1137
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 CMS-10357.Transmittal 371.pdf | Supplementary Document |
| CMS-10357_Instrument_Elements.pdf | Supplementary Document |
 CMS-10357_Supporting_Statement_Part_A (11-25-14).docx | Supporting Statement A |
 State Medicaid Agency Processing of Rescreening Application |
Information collection |
| Provider Rescreening |
Information collection |
| Site Visits |
Information collection |
| Collection of SSN and DOBs |
Information collection |
| Fingerprints - Medicaid |
Information collection |
| Fingerprints - Medicare |
Information collection |
| Medicare Enrollment Application Fee Waiver Request |
Information collection |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201410-0938-003 | Reinstatement without change of a previously approved collection | 2014-10-03 | Approved with change | |
| 201103-0938-001 | New collection (Request for a new OMB Control Number) | 2011-03-01 | Approved with change | |
| 201010-0938-005 | New collection (Request for a new OMB Control Number) | 2010-10-20 | Comment filed on proposed rule |