Information Collection

Annual Report and Recordkeeping Requirements

IC 209359 under ICR 201612-0938-019 · OMB 0938-1232.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1232 can be found here:

Documents and Forms

Document Name Document Type
508_CMS-10476_Attachment_C_MLR_Report_Instructions.pdf Instruction
508_CMS-10476_Attachment_D_Crosswalk.pdf Other-Crosswalk
CMS-10476 MLR Report 508_CMS-10476_Attachment_B_MLR_Report.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Report and Recordkeeping Requirements	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			508_CMS-10476_Attachment_C_MLR_Report_Instructions.pdf	Yes	No	Printable Only
Form	CMS-10476	MLR Report	508_CMS-10476_Attachment_B_MLR_Report.pdf	Yes	Yes	Fillable Printable
Other-Crosswalk			508_CMS-10476_Attachment_D_Crosswalk.pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 616	Number of Respondents for Small Entity: 25

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	616	616
Annual IC Time Burden (Hours)	28,980	28,980
Annual IC Cost Burden (Dollars)	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.