Information Collection

Information Collection Requirements In Bpo-500-f, Third Party Liability For Medical Assistance, Ffp Rates For Skilled Professional Medical Personnel & Supporting Staff

IC 113781 under ICR 199103-0938-003 · OMB 0938-0459.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0459 can be found here:

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENTS IN BPO-500-F, THIRD PARTY LIABILITY FOR MEDICAL ASSISTANCE, FFP RATES FOR SKILLED PROFESSIONAL MEDICAL PERSONNEL & SUPPORTING STAFF	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-R-78				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	52	52
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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