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Information Collection

Payer's Request For Identifying Number Of Supplier Or Provider Of Medical And Health Care Services

IC 129103 under ICR 198304-1545-005 · OMB 1545-0178.

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PAYER'S REQUEST FOR IDENTIFYING NUMBER OF SUPPLIER OR PROVIDER OF MEDICAL AND HEALTH CARE SERVICES
 
No Migrated
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 4686 No No


    

3,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,000 0 0 0 0 3,000
Annual IC Time Burden (Hours) 1,000 0 0 0 0 1,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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