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