View Information Collection (IC)

View Information Collection (IC)

IC Title:	Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.111 45 CFR 146.115 45 CFR 146.117 45 CFR 146.150 45 CFR 146.152 45 CFR 146.160 45 CFR 146.180

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10430	Model_Election_Exemption	CMS-10430_Model_Election_Exemption.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10430	Model_Notice_to_Enrollees	CMS-10430_Model_Notice_to_Enrollees.pdf		Yes	No	Fillable Fileable

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: 4,800	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	39,831,442	0	2,928,892	0	36,902,550	0
Annual IC Time Burden (Hours)	3,760,421	0	841,638	0	2,918,783	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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.