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

View Information Collection (IC)

EOB
 
No Modified
 
Mandatory
 
42 CFR 423.128 42 CFR 422.111(b)(12) 42 CFR 423.104 42 CFR 423.120 42 CFR 422.216

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10453 Yes No Fillable Fileable
Form and Instruction CMS-10453 Yes No Fillable Fileable
Form and Instruction CMS-10453 Yes No Fillable Fileable
Form and Instruction CMS-10453 Yes No Fillable Fileable
Form and Instruction CMS-10452 Yes No Fillable Fileable
Form and Instruction CMS-10453 Yes No Fillable Fileable
Form and Instruction CMS-10453 Yes No Fillable Fileable
Form and Instruction CMS-10453 Yes No Fillable Fileable
Instruction Yes No Printable Only
Instruction Yes No Fillable Printable
Instruction Yes No Fillable Printable
Instruction Yes No Fillable Printable
Instruction Yes No Fillable Printable
Instruction Yes No Fillable Printable
Instruction Yes No Fillable Printable
Form and Instruction CMS-10453 Yes Yes Fillable Fileable

Health Health Care Services

 

1,065 0
   
Individuals or Households
 
   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 1,065 0 -5,703 0 6,768 0
Annual IC Time Burden (Hours) 10,650 0 -87,110 0 97,760 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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