Information Collection

State Medicaid Quality Control Sample Selection Lists

IC 112969 under ICR 199004-0938-005 · OMB 0938-0147.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0147 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

STATE MEDICAID QUALITY CONTROL SAMPLE SELECTION LISTS

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-319				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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	660	660
Annual IC Time Burden (Hours)	21,120	21,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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