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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Application and Eligibility (2010)
Modified
100000
84000
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Application and Eligibility (2011)
Modified
50000
42000
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Application and Eligibility (2012)
Modified
50000
42000
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Application and Eligibility (2013)
Modified
50000
42000
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2010)
Modified
50000
8000
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2011)
Modified
33333
5333
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2012)
Modified
33333
5333
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2013)
Modified
33333
5333
0
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
Form and Instruction
CMS-10334
Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Total burden requested under this ICR:
399999
233999
0
To view an IC, click on IC Title