Information Collection

Intermediary's Request To Hospitals For Medical Information On Inpatient Claims For Statutorily-excluded Services

IC 113166 under ICR 198409-0938-013 · OMB 0938-0224.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

INTERMEDIARY'S REQUEST TO HOSPITALS FOR MEDICAL INFORMATION ON INPATIENT CLAIMS FOR STATUTORILY-EXCLUDED SERVICES

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	HCFA-9026				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 722

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	722	-2,599,278	2,600,000
Annual IC Time Burden (Hours)	183	-433,150	433,333
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.

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