Information Collection List

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