Information Collection

Referral And Treatment Plan

IC 112592 under ICR 197703-0938-002 · OMB 0938-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0036 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	REFERRAL AND TREATMENT PLAN	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	SSA-2043	No	No
Form	SSA-2043A	No	No
Form	HCFA-2043	No	No
Form	HCFA-2043A	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 396	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	168,000	144,000	24,000
Annual IC Time Burden (Hours)	5,600	1,600	4,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.