Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Modified 87 7 0 Form and Instruction CMS-10198 Creditable Coverage Disclosure to CMS
Form CMS-10198 CC Form (screen shot)
Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Modified 87128 7261 0 Form and Instruction CMS-10198 Creditable Coverage Disclosure to CMS
Form CMS-10198 CC Form (screen shot)
State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Modified 50 4 0
Total burden requested under this ICR: 87265 7272 0  
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