MEDICAID STATE AGENCY THIRD PARTY LIABILITY INVENTORY FORM

ICR 198905-0938-008

OMB: 0938-0414

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0414 198905-0938-008
Historical Active 198904-0938-041
HHS/CMS
MEDICAID STATE AGENCY THIRD PARTY LIABILITY INVENTORY FORM
No material or nonsubstantive change to a currently approved collection   No
Emergency 05/04/1989
Approved with change 05/04/1989
Retrieve Notice of Action (NOA) 05/04/1989
  Inventory as of this Action Requested Previously Approved
09/30/1989 09/30/1989 09/30/1989
56 0 56
672 0 672
0 0 0

MEDICAID, PROGRAM INVENTORY, LIABILITY INSURANCE, LEGAL RESPONSIBILIT HCFA USES THIS FORM TO ASSIST MEDICAID STATE AGENCIES IN THEIR RESPONSIBILITY OF ENSURING THAT MEDICAID IS THE "PAYOR OR LAST RESORT"

None
None


No

1
IC Title Form No. Form Name
MEDICAID STATE AGENCY THIRD PARTY LIABILITY INVENTORY FORM HCFA-464

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 56 56 0 0 0 0
Annual Time Burden (Hours) 672 672 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
05/04/1989


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