Information Collection

Determining Liability Of Third Parties -- Hcfa A-107, Third Party Liability (tpl) State Plan Preprint -- Hcfa Sp-1, Medicaid, -- 42 Cfr 433.138

IC 113885 under ICR 199306-0938-008 · OMB 0938-0502.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0502 can be found here:

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Information Collection (IC) Details

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IC Title:	DETERMINING LIABILITY OF THIRD PARTIES -- HCFA A-107, THIRD PARTY LIABILITY (TPL) STATE PLAN PREPRINT -- HCFA SP-1, MEDICAID, -- 42 CFR 433.138	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-107				No	No
Form	HCFA SP-2				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: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,566,666	3,566,666
Annual IC Time Burden (Hours)	171,165	171,165
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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