Information Collected On Provider Refunds, Section 3401 Of Intermediary Manual, And Section 7080 Of Carrier Manual

INFORMATION COLLECTED ON PROVIDER REFUNDS, SECTION 3401 OF INTERMEDIARY MANUAL, AND SECTION 7080 OF CARRIER MANUAL

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0383 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	INFORMATION COLLECTED ON PROVIDER REFUNDS, SECTION 3401 OF INTERMEDIARY MANUAL, AND SECTION 7080 OF CARRIER MANUAL	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-9049				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,500	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
Annual Number of Responses for this IC	5,500	5,500
Annual IC Time Burden (Hours)	1,375	1,375
Annual IC Cost Burden (Dollars)	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.