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

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

OMB: 0938-0224

IC ID: 113166

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INTERMEDIARY'S REQUEST TO HOSPITALS FOR MEDICAL INFORMATION ON INPATIENT CLAIMS FOR STATUTORILY-EXCLUDED SERVICES
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HCFA-9026 No No


    

722 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 722 0 -2,599,278 0 0 2,600,000
Annual IC Time Burden (Hours) 183 0 -433,150 0 0 433,333
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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