Request To Adjust Customary Charge Screen

REQUEST TO ADJUST CUSTOMARY CHARGE SCREEN

OMB: 0938-0206

IC ID: 113105

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Information Collection (IC) Details

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REQUEST TO ADJUST CUSTOMARY CHARGE SCREEN
 
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-455 No No


    

1,081 0
   
Private Sector Businesses or other for-profits
 
   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 1,081 0 -340,832 0 0 341,913
Annual IC Time Burden (Hours) 357 0 -56,628 0 0 56,985
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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