Information Collection

Provider-based Physician Questionnaire For Direct Dealing Provider

IC 113042 under ICR 198108-0938-003 · OMB 0938-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0179 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	PROVIDER-BASED PHYSICIAN QUESTIONNAIRE FOR DIRECT DEALING PROVIDER	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-284				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 333	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	333	333
Annual IC Time Burden (Hours)	42,623	42,623
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.