Information Collection

Information Collection Requirements In Bpo-500-f, Third Party Liability For Medical Assistance, Ffp Rates For Skilled Professional Medical Personnel & Supporting Staff

IC 113780 under ICR 198511-0938-001 · OMB 0938-0459.

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Information Collection (IC) Details

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IC Title:

INFORMATION COLLECTION REQUIREMENTS IN BPO-500-F, THIRD PARTY LIABILITY FOR MEDICAL ASSISTANCE, FFP RATES FOR SKILLED PROFESSIONAL MEDICAL PERSONNEL & SUPPORTING STAFF

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-R-78				No	No

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

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
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	342	342
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.