PAYER'S REQUEST FOR IDENTIFYING NUMBER OF SUPPLIER OR PROVIDER OF MEDICAL AND HEALTH CARE SERVICES

ICR 198107-1545-038

OMB: 1545-0178

Federal Form Document

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Document
Name
Status
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ICR Details
1545-0178 198107-1545-038
Historical Active 198104-1545-178
TREAS/IRS
PAYER'S REQUEST FOR IDENTIFYING NUMBER OF SUPPLIER OR PROVIDER OF MEDICAL AND HEALTH CARE SERVICES
Revision of a currently approved collection   No
Regular
Approved without change 09/11/1981
Retrieve Notice of Action (NOA) 07/30/1981
  Inventory as of this Action Requested Previously Approved
12/31/1983 12/31/1983 12/31/1981
3,000 0 3,000
1,000 0 3,000
0 0 0

SECTION 6109 OF THE CODE REQUIRES THAT RECIPIENTS FO MEDICAL AND HEALT CARE PAYMENTS FURNISH THEIR IDENTIFYING NUMBERS TO PAYERS WHO MUST REPORT THE PAYMENTS TO IRS. THIS FORM CAN BE USED BY PAYERS TO REQUES THE RECIPIENT'S IDENTIFYING NUMBER.

None
None


No

1
IC Title Form No. Form Name
PAYER'S REQUEST FOR IDENTIFYING NUMBER OF SUPPLIER OR PROVIDER OF MEDICAL AND HEALTH CARE SERVICES 4686

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,000 3,000 0 0 0 0
Annual Time Burden (Hours) 1,000 3,000 0 0 -2,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/30/1981


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