Information Collection

Information Collection Requirements Contained In Berc-371-fc, Appeals Procedures For Determinations That Affect Participation In Medicare

IC 166317 under ICR 198904-0938-048 · OMB 0938-0508.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0508 can be found here:

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENTS CONTAINED IN BERC-371-FC, APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT PARTICIPATION IN MEDICARE	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

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-103				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	250	250
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.