View Information Collection (IC)
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View Information Collection (IC)

SBC Disclosure
 
No Modified
 
Mandatory
 
45 CFR 147.200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Maternity Care Narrative Yes No Printable Only
Other-Diabetes 2 Narrative Yes No Printable Only
Other-Uniform Glossary Anchor Yes No Printable Only
Other-What the Plan Covers and What You Pay (No Answers) Yes No Printable Only
Other-Why This Matters for SBC (Yes Answers) Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Other-Completed SBC Template Yes No Fillable Fileable
Other-SBC Template Yes No Fillable Fileable
Other-Foot Fracture Narrative Yes No Printable Only
Instruction Yes No Printable Only
Other-Coverage Calculator Yes No Fillable Printable
Other-Template Yes No Printable Only
Other-Diabetes Guide Yes No Printable Only
Other-Glossary Anchor Yes No Printable Only
Other-Template Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Other-Uniform Glossary Yes No Printable Only
Form CMS-10407 Yes Yes Fillable Fileable
Other-SBC Template - Carolinian Yes No Printable Only
Other-Uniform Glossary - Carolinian Yes No Printable Only
Other-Why This Matters NO Answers - Carolinian Yes No Printable Only
Other-Why This Matters - Yes Answers - Carolinian Yes No Printable Only
Other-SBC Template - Chamorro Yes No Printable Only
Other-Uniform glossary - Chamorro Yes No Printable Only
Other-Why This Matters No Answers - Chamorro Yes No Printable Only
Other-Why This Matters YES Answers - Chamorro Yes No Printable Only
Other-SBC Template - Chinese Yes No Printable Only
Other-Uniform Glossary - Chinese Yes No Printable Only
Other-Why This Matters NO Answers - Chinese Yes No Printable Only
Other-Why This Matters Yes Answers - Chinese Yes No Printable Only
Other-SBC Template - Pennsylvania Dutch Yes No Printable Only
Other-Uniform Glossary - Pennsylvania Dutch Yes No Printable Only
Other-Why This Matters No Answers - Pennsylvania Dutch Yes No Printable Only
Other-Why This Matters YES Answers - Pennsylvania Dutch Yes No Printable Only
Other-SBC Template - Samoan Yes No Printable Only
Other-Uniform Glossary - Samoan Yes No Printable Only
Other-Why This Matters No Answers - Samoan Yes No Printable Only
Other-Why This Matters Yes Answers Yes No Printable Only
Other-SBC Template - Spanish Yes No Printable Only
Other-Uniform Glossary - Spanish Yes No Printable Only
Other-Why This Matters No Answers - Spanish Yes No Printable Only
Other-Why This Matters Yes Answers - Spanish Yes No Printable Only
Other-Why This Matters Yes Answers - Spanish Yes No Printable Only
Other-SBC Template - Tagalog Yes No Printable Only
Other-Uniform Glossary - Tagalog Yes No Printable Only
Other-Why This Matters No Answers - Tagalog Yes No Printable Only
Other-Why This Matters Yes Answers - Tagalog Yes No Printable Only

Health Health Care Services

 

679 35
   
Private Sector Businesses or other for-profits
 
   70 %

  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 24,211,211 0 0 0 0 24,211,211
Annual IC Time Burden (Hours) 203,564 0 0 0 0 203,564
Annual IC Cost Burden (Dollars) 10,494,154 0 0 0 0 10,494,154

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