Information Collection

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

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded

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