View Information Collection (IC)

View Information Collection (IC)

IC Title:	DDR Product Data (CMS-367c)	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
Instruction			CMS-367c - Screenshots of MDP Web-Based Instructions_07.2021_508.pdf		Yes	Yes	Fillable Fileable
Form	CMS-367c	Product Data	CMS-367c - Screenshots of MDP Online Data Entry_07.2021_508.pdf		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: 749	Number of Respondents for Small Entity: 0

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	749	0	0	6	0	743
Annual IC Time Burden (Hours)	32,582	0	0	261	0	32,321
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-367c - Crosswalk	CMS Form-367c_Product Data_Crosswalk_07.2021_508.pdf	02/26/2021

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