Information Collection

Health Maintenance Organization Qualification Application, Health Maintenance Organization Expansion Application, Competitive Medical Plan Application

IC 110218 under ICR 198409-0915-002 · OMB 0915-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0065 can be found here:

1985-10-29 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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Information Collection (IC) Details

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IC Title:

HEALTH MAINTENANCE ORGANIZATION QUALIFICATION APPLICATION, HEALTH MAINTENANCE ORGANIZATION EXPANSION APPLICATION, COMPETITIVE MEDICAL PLAN APPLICATION

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HRSA-901-1				No	No
Form	2, & 3				No	No

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	26	34
Annual IC Time Burden (Hours)	6,000	2,600	3,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.