View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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-576A	Health Insurance Benefits Agreement	CMS-576A form. 03.23.23.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-576	ORGAN PROCUREMENT ORGANIZATION (OPO) REQUEST FOR DESIGNATION AS AN OPO	CMS-576 form..03.23.23.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: Orgran Procurement Organization System (OPOS)	FR Citation: 71 FR 29336

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	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	16	0	-42	0	58	0
Annual IC Time Burden (Hours)	32	0	3	0	29	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-576. 03.23.23.pdf	10/18/2023
Crosswalk	Change Crosswalk for CMS-576A 03.21.23.pdf	10/18/2023

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