Information Collection

Health Maintenance Organization Qualification Application, Health Maintenance Organization Expansion Application, Competitive Medical Plan Application

IC 110219 under ICR 198510-0915-003 · OMB 0915-0065.

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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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 195

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	195	135	60
Annual IC Time Burden (Hours)	19,500	13,500	6,000
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.