OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Pre-Existing Condition Insurance Plan and Supporting Regulations

OMB 0938-1100 · HHS/CMS.

OMB 0938-1100

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10339 Proposal Modification Form and Instruction
Form CMS-10339 Record Retention Form and Instruction
Form CMS-10339 Audit Form and Instruction
Form CMS-10339 Audited Financial Report Form and Instruction
Form CMS-10339 Quarterly and Monthly Reporting Form and Instruction
state_solicitation.pdf Supplementary Document
PCIP Model Contract.pdf Supplementary Document
CMS-10339 Supporting_Statement_Part_A.pdf Supporting Statement A
Proposal Modification Form and Instruction
Record Retention Form and Instruction
Audit Form and Instruction
Reports of Insurer Dumping (42 CFR 152.28)
Audited Financial Report Form and Instruction
Quarterly and Monthly Reporting Form and Instruction
Fraud, Waste, and Abuse (42 CFR 152.27)
Payment Invoices (42 CFR 152.32)

All Historical Document Collections

201308-0938-003 Approved without change	Extension without change of a currently approved collection	2013-08-06
201102-0938-007 Withdrawn and continue	Revision of a currently approved collection	2011-02-10
201012-0938-022 Approved without change	Extension without change of a currently approved collection	2010-12-30
201012-0938-019 Approved without change	Revision of a currently approved collection	2010-12-30
201007-0938-013 Preapproved	New collection (Request for a new OMB Control Number)	2010-07-26