Information Collection

Requirement To Disclose Hmo Financial Information To Members

IC 110215 under ICR 198408-0915-010 · OMB 0915-0064.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	REQUIREMENT TO DISCLOSE HMO FINANCIAL INFORMATION TO MEMBERS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 210	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	210	82	128
Annual IC Time Burden (Hours)	105	41	64
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.