View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0935	ICR Reference No: 200608-0938-002
Status: Historical Active	Previous ICR Reference No: 200512-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Advantage Applications
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/21/2006
	Date Received in OIRA: 08/22/2006
Terms of Clearance: CMS will update the burden and number of responses in accordance with any annual changes that occur during the MA contract period.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2008	36 Months From Approved	11/30/2006
Responses	110	0	90
Time Burden (Hours)	3,400	0	2,770
Cost Burden (Dollars)	0	0	0

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Advantage Applications	CMS-10117, CMS-10136, CMS-10135, CMS-10119, CMS-10118	, , , ,

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	110	90	20
Annual Time Burden (Hours)	3,400	2,770	630
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden change for this package is due to the response to questions from potential 2007 applications related to CMS-10136. Revisions were made to that application type after the emergency approval was granted.

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