View Information Collection (IC)

View Information Collection (IC)

IC Title:	Health Insurance Issuer Submission of the Preliminary Justification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-Word Document			Preliminary Justification Submission Function.docx		Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 974	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: 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	974	974	0	0	0	0
Annual IC Time Burden (Hours)	10,714	10,714	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Rate Summary Worksheet	CMS-10379.Rate_Summary_Form_(7-12-11)_w_comment_changes_highlighted.xls	08/15/2011

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