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

View Information Collection (IC)

Forms used to update the DUA Information
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-R-235 DUA Certificate of Disposition RIF COD_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-R-235 QE DUA Signature Addendum QE DUA Signature Addendum_.docx Yes Yes Fillable Fileable
Form and Instruction CMS-R-235 NDTR DUA Signature Addendum NDTR DUA Signature Addendum.docx Yes Yes Fillable Fileable
Form and Instruction CMS-R-235 Contractor DUA Signature Addendum Contractor DUA Signature Addendum_.docx Yes Yes Fillable Fileable

Health Health Care Services

 

2,800 0
   
Private Sector Not-for-profit institutions
 
   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 2,800 0 -2,800 0 0 5,600
Annual IC Time Burden (Hours) 476 0 -476 0 0 952
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Change - RIF COD RIF-COD REDLINE.pdf 05/27/2025
RIF COD_JobAid RIF COD_JobAid.pdf 05/28/2025
Contractor Signature Addendum_JobAid Contractor Signature Addendum_JobAid.pdf 05/28/2025
QE Signature Addendum_JobAid QE Signature Addendum_JobAid.pdf 05/28/2025
NDTR Signature Addendum_JobAid NDTR Signature Addendum_JobAid.pdf 05/28/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.