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Notice To Patient - Third Party Case

IC 116505 under ICR 197906-0990-001 · OMB 0990-0014.

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NOTICE TO PATIENT - THIRD PARTY CASE
 
No Migrated
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form OS-13-79 No No


    

500 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,000 0 0 1,000 0 0
Annual IC Time Burden (Hours) 100 0 0 100 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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