Information Collection

Information Collection Requirements In Bqc-64-f, State Plan Requirements And Other Provisions Relating To Third Party Liability (tpl) Programs

IC 113972 under ICR 198909-0938-005 · OMB 0938-0555.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0555 can be found here:

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENTS IN BQC-64-F, STATE PLAN REQUIREMENTS AND OTHER PROVISIONS RELATING TO THIRD PARTY LIABILITY (TPL) PROGRAMS	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-122				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	55	55
Annual IC Cost Burden (Dollars)	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.