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Demonstration Project For Calculating Adjusted Average Per Capita Costs
DEMONSTRATION PROJECT FOR CALCULATING ADJUSTED AVERAGE PER CAPITA COSTS
OMB: 0938-0092
IC ID: 112855
OMB.report
HHS/CMS
OMB 0938-0092
ICR 198312-0938-018
IC 112855
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
DEMONSTRATION PROJECT FOR CALCULATING ADJUSTED AVERAGE PER CAPITA COSTS
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-123,
No
No
Form
123A, 123-L
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,500
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
1,500
0
0
0
0
1,500
Annual IC Time Burden (Hours)
750
0
0
0
0
750
Annual IC Cost Burden (Dollars)
0
0
0
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.