MEDICAID STATE AGENCY THIRD PARTY LIABILITY INVENTORY FORM

ICR 199012-0938-006

OMB: 0938-0414

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0414 199012-0938-006
Historical Active 198907-0938-009
HHS/CMS
MEDICAID STATE AGENCY THIRD PARTY LIABILITY INVENTORY FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 02/26/1991
Retrieve Notice of Action (NOA) 12/14/1990
  Inventory as of this Action Requested Previously Approved
02/28/1994 02/28/1994
56 0 0
448 0 0
0 0 0

MEDICAID, PROGRAM INVENTORY, LIABILITY INSURANCE, LEGAL RESPONSIBILIT THE PURPOSE OF THE MEDICAID STATE AGENCY THIRD PARTY LIABILITY INVENTO FORM IS TO ASSIST MEDICAID STATE AGENCIES IN THEIR RESPONSIBILITY TO RESPONSIBLE FOR THE LEGAL LIABILITY TO PAY FOR HEALTH CARE AND SERVICE ARISING OUT OF INJURY OR DISEASE.

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 0 0 0 56 0
Annual Time Burden (Hours) 448 0 0 0 448 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.
12/14/1990


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