Information Collection

Applicatin to Participate in the IVIG Demonstration

IC 211762 under ICR 201801-0938-002 · OMB 0938-1246.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1246 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10518 Applicatin to Participate in the IVIG Demonstration Form and Instruction
CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici CMS-10518 IVIG Application October 24 2017.pdf Form and Instruction
CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici CMS-10518 Spanish IVIG Application October 24 2017.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Applicatin to Participate in the IVIG Demonstration	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10518	Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application	CMS-10518 IVIG Application October 24 2017.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10518	Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application	CMS-10518 Spanish IVIG Application October 24 2017.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,220	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,220	-280	1,500
Annual IC Time Burden (Hours)	305	-70	375
Annual IC Cost Burden (Dollars)	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.