Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Establishing a reassignment of benefits enrollment application New 100000 25000 0 Form and Instruction CMS-855R
Terminating a Reassignment New 100000 25000 0 Form and Instruction CMS-855R
Total burden requested under this ICR: 200000 50000 0  
To view an IC, click on IC Title