Information Collection

Medicare Contract Application For Federally Qualified Health Maintenance Organizations, Medicare Contract Application: Competitive Medical Plan, Qualification Application

IC 113810 under ICR 199310-0938-019 · OMB 0938-0470.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0470 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	MEDICARE CONTRACT APPLICATION FOR FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS, MEDICARE CONTRACT APPLICATION: COMPETITIVE MEDICAL PLAN, QUALIFICATION APPLICATION	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.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-901-1	No	No
Form	901-2	No	No
Form	901-3	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65	65
Annual IC Time Burden (Hours)	6,500	6,500
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.