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Federal forms, ICRs, and supporting documents

Information Collection Request

HIPAA Administrative Simplification (Non-Privacy/Security) Complaint Form (CMS-10148)

ICR 202606-0938-005 · OMB 0938-0948 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CMS10148 HIPAA Non-privacy complaint form Form and Instruction Modified Available
CMS10148 Non Substantive Change Memo.docx Justification for No Material/Nonsubstantive Change Uploaded 2026-06-09 Available
CMS10148 Redline.pdf Supplementary Document Uploaded 2026-06-09 Available
CMS-10148_Supporting_Statement_Part_A.docx Supporting Statement A Uploaded 2025-09-26 Available
IC Document Collections
IC IDCollectionTypeStatusForm
223444 Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification (A.S.) Complaint Form Form and Instruction ModifiedHIPAA Non-privacy complaint form
ICR Details
0938-0948 202606-0938-005
Received in OIRA 202509-0938-028
HHS/CMS OIT
HIPAA Administrative Simplification (Non-Privacy/Security) Complaint Form (CMS-10148)
No material or nonsubstantive change to a currently approved collection   No
Regular 06/11/2026
  Requested Previously Approved
04/30/2029 04/30/2029
400 400
400 400
18,256 18,256
This revised collection of information modifies the current form to remove the HIPAA Privacy/Security complaint category section. The section is revised to read as follows: “Identify the HIPAA Non-Privacy/Security complaint category” section of the complaint form. On this revised version of the form, complainants are given an opportunity to check the “Unique Identifiers” and “Operating Rules” option to additionally categorize the type of HIPAA complaint being filed. The revised form also requests an email address for filed against entities, if available. Finally, the revised form is structured so that it be expanded to collect additional HIPAA Administrative Simplification complaint types in the future.
PL: Pub.L. 104 - 191 1300d Name of Law: Health Insurance Portability and Accountability Act
  
None
Not associated with rulemaking
  90 FR 27540 06/27/2025
90 FR 45941 09/24/2025
No
  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 400 400 0 0 0 0
Annual Time Burden (Hours) 400 400 0 0 0 0
Annual Cost Burden (Dollars) 18,256 18,256 0 0 0 0
No
No
$0
No
    Yes
    Yes
No
No
No
No
Malcolm Wilson 667 414-0087 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/11/2026