Information Collection

Third Party Premium Billing Request, Medicare

IC 112613 under ICR 199312-0938-003 · OMB 0938-0041.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0041 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-2384				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	6,250	6,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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