Medicaid Quality Control Third Party Resource Worksheet (hcfa 301c)

MEDICAID QUALITY CONTROL THIRD PARTY RESOURCE WORKSHEET (HCFA 301C)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0108 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	MEDICAID QUALITY CONTROL THIRD PARTY RESOURCE WORKSHEET (HCFA 301C)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-301C				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 160,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	160,000	4,562	155,438
Annual IC Time Burden (Hours)	52,192	1,477	50,715
Annual IC Cost Burden (Dollars)	0	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.