View Information Collection (IC)

View Information Collection (IC)

IC Title:	Premium Payment (2012)	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-10334	PreExistingConditionPlan_EnrollmentForm_508	PreExistingConditionPlan_EnrollmentForm_508.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10334	PreExistingConditionPlan_EnrollmentForm_Spanish_508	PreExistingConditionPlan_EnrollmentForm_Spanish_508.pdf		Yes	No	Fillable Fileable

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: 33,333	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	33,333	0	0	0	0	33,333
Annual IC Time Burden (Hours)	5,333	0	0	0	0	5,333
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.