View Information Collection (IC)

View Information Collection (IC)

IC Title:	DDR Quarterly Pricing Data Specifications (CMS-367a)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-367a	DDR Quarterly Pricing Data Specifications	DDR Screenshots for CMS-367a_b_c_CLEAN_updated_7.12.16.docx		Yes	Yes	Fillable Fileable
Instruction			CMS-367 - Instructions to Labelers -CLEAN - updated 4_21_16.docx		Yes	Yes	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: 610	Number of Respondents for Small Entity: 100

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	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	2,440	0	-10,370	0	0	12,810
Annual IC Time Burden (Hours)	84,912	0	-3,527,691	0	0	3,612,603
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.