Information Collection

Triage--coordinated Care Of The Elderly (billing Forms)

IC 113017 under ICR 198104-0938-005 · OMB 0938-0167.

Documents and Forms

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Information Collection (IC) Details

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IC Title:	TRIAGE--COORDINATED CARE OF THE ELDERLY (BILLING FORMS)	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	HCFA-269	No	No
Form	THRU 274	No	No
Form	-HCFA-1453D,	No	No
Form	1483D,	No	No
Form	1487D,	No	No
Form	1490D &	No	No
Form	1491D	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,458	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44,115	44,115
Annual IC Time Burden (Hours)	3,725	3,725
Annual IC Cost Burden (Dollars)	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.