Information Collection

Information Collection Requirement In Bpd 302-f, Medicare Secondary Payer -- 42 Cfr 411.25, 411.32(c), 411.65(b)(2), And 42 Cfr 489.20(f) And Related Questions

IC 113986 under ICR 199212-0938-004 · OMB 0938-0564.

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENT IN BPD 302-F, MEDICARE SECONDARY PAYER -- 42 CFR 411.25, 411.32(C), 411.65(B)(2), AND 42 CFR 489.20(F) AND RELATED QUESTIONS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

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-136				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 417,235	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	417,235	417,235
Annual IC Time Burden (Hours)	661,864	661,864
Annual IC Cost Burden (Dollars)	0	0

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