Information Collection

State Agency Work Sheets For Verifying Exclusions From The Prospective Payment System

IC 166265 under ICR 198503-0938-027 · OMB 0938-0358.

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Documents and Forms

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Document Name	Document Type

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IC Title:

STATE AGENCY WORK SHEETS FOR VERIFYING EXCLUSIONS FROM THE PROSPECTIVE PAYMENT SYSTEM

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-437, A				No	No
Form	B				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,537

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	Previously Approved
Annual Number of Responses for this IC	2,537	2,537
Annual IC Time Burden (Hours)	634	634
Annual IC Cost Burden (Dollars)	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.