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Physician's Statement Regarding Patient's Capability To Manage Payments

IC 177126 under ICR 198102-3220-045 · OMB 3220-0103.

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PHYSICIAN'S STATEMENT REGARDING PATIENT'S CAPABILITY TO MANAGE PAYMENTS
 
No Migrated
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form G-478 No No


    

5,000 0
   
Private Sector Businesses or other for-profits
 
   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 5,000 0 0 0 0 5,000
Annual IC Time Burden (Hours) 417 0 0 0 0 417
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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