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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

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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:

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

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 %

	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

Title	Document	Date Uploaded

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