View Information Collection Request (ICR) Package

View ICR - Agency Submission

Comment Period Closed - Comments are accepted for the first 30 days of OIRA's review. See FAQ page for more information.

OMB Control No: 0938-0948	ICR Reference No: 202509-0938-028
Status: Received in OIRA	Previous ICR Reference No: 202208-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: OIT
Title: HIPAA Administrative Simplification (Non-Privacy/Security) Complaint Form (CMS-10148)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 11/04/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	400	0
Time Burden (Hours)	400	0
Cost Burden (Dollars)	18,256	0

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	400	379	21
Annual Time Burden (Hours)	400	379	21
Annual Cost Burden (Dollars)	18,256	18,256	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Increase due to estimate adjustment to 400 annual submissions based on the average number of submissions received over the last three years via submission of the complaint form electronically, via U.S. mail, and the ASETT system.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Malcolm Wilson 667 414-0087 malcolm.wilson@cms.hhs.gov