Information Collection

Requests For Medicare Payment By Municipal Health Services Program (mhsp) Clinics

IC 112846 under ICR 198405-0938-005 · OMB 0938-0091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0091 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

View Information Collection (IC)

IC Title:	REQUESTS FOR MEDICARE PAYMENT BY MUNICIPAL HEALTH SERVICES PROGRAM (MHSP) CLINICS	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA 127&				No	No
Form	127A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 19	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	126,008	51,008	75,000
Annual IC Time Burden (Hours)	18,901	-18,599	37,500
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.