Information Collection

Information Collection Requirements In Bpo-52-f, Identification Of Third Party Liability (tpl) Resources For Medical Assistance & Tpl State Plan Preprint

IC 113883 under ICR 198703-0938-012 · OMB 0938-0502.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0502 can be found here:

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENTS IN BPO-52-F, IDENTIFICATION OF THIRD PARTY LIABILITY (TPL) RESOURCES FOR MEDICAL ASSISTANCE & TPL STATE PLAN PREPRINT	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA R-106				No	No
Form	HCFA SP-2				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,566,666	3,566,666
Annual IC Time Burden (Hours)	263,309	263,309
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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