Information Collection

Chronic Renal Disease Medical Evidence Report

IC 112639 under ICR 198710-0938-004 · OMB 0938-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0046 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	CHRONIC RENAL DISEASE MEDICAL EVIDENCE REPORT	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-2728				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	45,000	15,000	30,000
Annual IC Time Burden (Hours)	11,250	3,750	7,500
Annual IC Cost Burden (Dollars)	0	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.