Information Collection

"medicare", Information Collection Requirements In 405.2112, 405.2123, 405.2134, 405.2136, 405.2137, 405.2138, 405.2139, 405.2140 And 405.2171

IC 113626 under ICR 198805-0938-007 · OMB 0938-0386.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0386 can be found here:

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Information Collection (IC) Details

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IC Title:	"MEDICARE", INFORMATION COLLECTION REQUIREMENTS IN 405.2112, 405.2123, 405.2134, 405.2136, 405.2137, 405.2138, 405.2139, 405.2140 AND 405.2171	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-52				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,700	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,700	300	1,400
Annual IC Time Burden (Hours)	69,681	-10,263	79,944
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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