HEALTH PREPAYMENT DATA CARD CODING SHEET

ICR 198309-0938-003

OMB: 0938-0161

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
113007 Migrated
ICR Details
0938-0161 198309-0938-003
Historical Active 198203-0938-017
HHS/CMS
HEALTH PREPAYMENT DATA CARD CODING SHEET
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 10/20/1983
Retrieve Notice of Action (NOA) 09/26/1983
  Inventory as of this Action Requested Previously Approved
09/30/1986 09/30/1986
156 0 0
10,192 0 0
0 0 0

THIS FORM IS USED BY HEALTH MAINTENANCE ORGANIZATION AND GROUP PRACTIC PREPAYMENT PLANS TO NOTIFY HCFA OF NAME AND HEALTH INSURANCE CLAIM NUMBER OF MEDICAL ENROLLEES AND DISENROLLEES, AND EFFECTIVE DATE OF EACH.

None
None


No

1
IC Title Form No. Form Name
HEALTH PREPAYMENT DATA CARD CODING SHEET HCFA-1929

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 156 0 0 0 156 0
Annual Time Burden (Hours) 10,192 0 0 0 10,192 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/26/1983


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