Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Early Retiree Reinsurance Program - Private Application Removed 0 0 0 Form CMS-10321 Deliberative Document
Instruction
Early Retiree Reinsurance Program - Public Application Removed 0 0 0 Form CMS-10321 Deliberative Document
Instruction
Early Retiree Reinsurance Program Appeals (Private), for Program Year 4 New 15 120 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3 New 100 800 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Public), for Program Year 4 New 15 120 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3 New 100 800 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4 New 10 80 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4 New 10 80 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2 New 3000 24000 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3 New 1200 105600 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4 New 30 2640 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2 New 3000 264000 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3 New 1200 105600 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4 New 30 2640 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Fraud and Abuse Procedures (Private) - Year 1 Removed 0 0 0
Fraud and Abuse Procedures (Public) - Year 1 Removed 0 0 0
Private Application Update Year 2_3_4 New 458 458 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Private CHOW Years 2_3_4 Modified 38 38 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Private Data Inaccuracies Years 2_3_4 Modified 20 1760 0 Instruction
Form CMS-10321 ERRP Collection Instrument
Private Fraud and Abuse Procedures Years 2_3_4 Modified 764 15280 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Private Maintenance of Records Year 2_3_4 Modified 3055 18330 0 Instruction
Instruction
Private Written Agreement Year 2_3_4 Modified 764 764 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Public Application Update Year 2_3_4 New 458 458 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Public CHOW Years 2_3_4 Modified 2 2 0 Instruction
Form CMS-10321 ERRP Collection Instrument
Public Data Inaccuracies Years 2_3_4 Modified 20 1760 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Public Fraud and Abuse Procedures Years 2_3_4 Modified 764 15280 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Public Maintenance of Records Year 2_3_4 Modified 3055 18330 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Public Written Agreement Year 2_3_4 Modified 764 764 0 Instruction
Form CMS-10321 Revised ERRP Collection Instrument
Reimbursement Requests (Private) Removed 0 0 0
Reimbursement Requests (Public) Removed 0 0 0
Written Agreements (Private ) - Year 1 Removed 0 0 0
Written Agreements (Public) - Year 1 Removed 0 0 0
Total burden requested under this ICR: 18872 579704 0  
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