View Information Collection (IC)

View Information Collection (IC)

IC Title:	Appointment of Representative and Supporting Regulations in 42 CFR 405.910	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1696 English	APPOINTMENT??OF??REPRESENTATIVE	cms1696.pdf		Yes	Yes	Paper Only
Form and Instruction	CMS--1696 SP	NOMBRAMIENTO DE REPRESENTANTE	1696-span.pdf		Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,455,461	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	5,455,461	0	0	0	0	5,455,461
Annual IC Time Burden (Hours)	6,819	0	0	0	0	6,819
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.