Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Change of Ownership (Private) New 33 33 0
Change of Ownership (Public) New 17 17 0
Data Inaccuracies (Private) New 2000 32000 0
Data Inaccuracies (Public) New 1000 16000 0
Early Retiree Reinsurance Program - Private Application New 3000 105000 0 Form CMS-10321 ERRP Application
Instruction
Early Retiree Reinsurance Program - Public Application New 1500 52500 0 Form CMS-10321 ERRP Application
Instruction
Fraud and Abuse Procedures (Private) - Out Years New 754 15080 0
Fraud and Abuse Procedures (Private) - Year 1 New 6000 120000 0
Fraud and Abuse Procedures (Public) - Out Years New 371 7420 0
Fraud and Abuse Procedures (Public) - Year 1 New 3000 60000 0
Mainenance of Records (Private) New 3000 18000 0
Maintenance of Records (Public) New 1500 9000 0
Reimbursement Requests (Private) New 6000 270000 0
Reimbursement Requests (Public) New 3000 135000 0
Written Agreements (Private ) - Year 1 New 9000 9000 0
Written Agreements (Private) - Out Years New 754 754 0
Written Agreements (Public) - Out Years New 371 371 0
Written Agreements (Public) - Year 1 New 4500 4500 0
Total burden requested under this ICR: 45800 854675 0  
To view an IC, click on IC Title