Information Collection

Medicare Mental Health Demonstration Cost & Statistical Report

IC 113076 under ICR 198110-0938-002 · OMB 0938-0196.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

MEDICARE MENTAL HEALTH DEMONSTRATION COST & STATISTICAL REPORT

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	266A	No	No
Form	HCFA-266,	No	No
Form	266Q	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	405	405
Annual IC Time Burden (Hours)	3,330	3,330
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.

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