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 56 5 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 141286 11774 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 58 5 0 Form and Instruction CMS-10198 Creditable Coverage Disclosure to CMS
Form CMS-10198 CC Form (screen shot)
Total burden requested under this ICR: 141400 11784 0  
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