Information Collection Request

Value in Opioid Use Disorder Treatment Demonstration (CMS-10728)

ICR 202305-0938-016 · OMB 0938-1388 · Received in OIRA

Forms and Documents

Document Name	Status
Form CMS-10728 Participation Agreement Form and Instruction	Removed
Form CMS-10728 Participant Survey Form and Instruction	Modified
Form CMS-10728 Beneficiary Survey Form and Instruction	Modified
Form CMS-10728 Beneficiary Notification Form and Instruction	Modified
Form CMS-10728 Request for Application Form and Instruction	Modified
CMS-10728_OUD_Supporting Statement - Part A.docx Supporting Statement A	2023-05-31
Value in Treatment 2022 Amendment No. 1 Sequestration (003).pdf Supplementary Document	2023-05-31
ViT RFA Attachment 2 prevalence rates.xlsx Supplementary Document	2020-12-03
ViT_OUD_Diagnosis_Codes.pdf Supplementary Document	2023-05-31
ViT PA Final clean 3.25.2021.pdf Supplementary Document	2023-05-31

IC Document Collections

IC ID	Document Title	Status
244606	Participation Agreement Form and Instruction	Removed
242941	Participant Financial Instruction	Modified
242940	Participant Compliance Audit Instruction	Modified
242939	Participant Survey Form and Instruction	Modified
242934	Beneficiary Survey Form and Instruction	Modified
242933	Beneficiary Notification Form and Instruction	Modified
242932	Request for Application Form and Instruction	Modified

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1388
Type of Information Collection	Extension without change of a currently approved collection
Previous ICR Reference No	202007-0938-012
Agency Tracking No	CMMI
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31