Information Collection

Medicare/medicaid - Health Insurance Common Claims Form And Instructions

IC 112480 under ICR 199009-0938-008 · OMB 0938-0008.

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Documents and Forms

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Document Name	Document Type

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IC Title:

MEDICARE/MEDICAID - HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS

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.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-1500	No	No
Form	HCFA-1490U	No	No
Form	HCFA-1490S	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	455,826,100	455,826,100
Annual IC Time Burden (Hours)	74,497,169	74,497,169
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.