Information Collection

Delivery Of Medical & Social Services To The Homebound Elderly, New York City -- Billing Forms

IC 113214 under ICR 198112-0938-022 · OMB 0938-0239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

DELIVERY OF MEDICAL & SOCIAL SERVICES TO THE HOMEBOUND ELDERLY, NEW YORK CITY -- 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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-245D				No	No
Form	HCFA-246D				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	667	667
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.