OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Applicatin to Participate in the IVIG Demonstration

IC 211762 under ICR 202104-0938-011 · OMB 0938-1246.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Applicatin to Participate in the IVIG Demonstration
 
No Modified
 
Required to Obtain or Retain Benefits
 

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 (English) IVIG-Final-English-App-02.03.21.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application (Spanish) IVIG-Final-Spanish-App-02.04.21.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

6,500 0
   
Individuals or Households
 
   0 %

  Requested 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 6,500 0 0 5,280 0 1,220
Annual IC Time Burden (Hours) 1,625 0 0 1,320 0 305
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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