View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10892	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form	CMS-10892.Fast Track - EMTALA - Mockup - final- 04032024.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: ASPEN Complaints/Incidents Tracking System (ACTS) 09-70-0565	FR Citation: 71 FR 29643

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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	600	0	600	0	0	0
Annual IC Time Burden (Hours)	50	0	50	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10892.Fast Track - GenIC Template (EMTALA)	CMS-10892.Fast Track - GenIC Template (EMTALA).docx	04/05/2024

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