Information Collection

Medicare Advantage Applications - Part C (CY 2011)

IC 8785 under ICR 200910-0938-008 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10237 Medicare Advantage Applications - Part C (CY 2011) Form
HSD Table Completion Instructions_09172009.doc Instruction
CMS-10237 HSD Tables HSD Tables 1-5 (2011--V3) xls.xls Form
CMS-10237 Part-C Medicare Advantage Application 2011PartC_MA_AppV15_09142009_CLEAN_Draft.docx Form and Instruction
2011PartC_MA_AppV15_09142009_REDLINED_Draft.docx 2011PartC_MA_AppV15_09142009_REDLINED_Draft IC Document
HSD Instructions _09112009_REDLINED.docx HSD Instructions _09112009_REDLINED IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Advantage Applications - Part C (CY 2011)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.501 42 CFR 422.503 42 CFR 422.504 42 CFR 422.506 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.524 42 CFR 422.527

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10237	HSD Tables	HSD Tables 1-5 (2011--V3) xls.xls	Yes	Yes	Paper Only
Instruction			HSD Table Completion Instructions_09172009.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10237	Part-C Medicare Advantage Application	2011PartC_MA_AppV15_09142009_CLEAN_Draft.docx	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 291	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	Previously Approved
Annual Number of Responses for this IC	291	24	267
Annual IC Time Burden (Hours)	9,547	3,057	6,490
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
2011PartC_MA_AppV15_09142009_REDLINED_Draft	2011PartC_MA_AppV15_09142009_REDLINED_Draft.docx	10/02/2009
HSD Instructions _09112009_REDLINED	HSD Instructions _09112009_REDLINED.docx	10/02/2009

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