Coverage Assistance Fund (CAF) Application

COVID–19 Provider Relief Programs Application and Attestation Portal, and Claims Reimbursement Submission Activities

Documents and Forms

Document Name Document Type
Form 3 Coverage Assistance Fund (CAF) Application Form
3 CAF Application Screenshots.pdf CAF Application Screenshots.pdf Form
3 CAF Application Screenshots.pdf CAF Application Screenshots.pdf Form

Information Collection (IC) Details

IC Title:	Coverage Assistance Fund (CAF) Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	CAF Application Screenshots.pdf	CAF Application Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	Number of Respondents for Small Entity: 1,000

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	15,000	15,000
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.