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Medicare/medicaid Health Insurance Common Claim Form And Instructions
MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS
OMB: 0938-0008
IC ID: 112484
OMB.report
HHS/CMS
OMB 0938-0008
ICR 199407-0938-002
IC 112484
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0008 can be found here:
2006-03-09 - Extension without change of a currently approved collection
2003-01-06 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS
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-1500
No
No
Form
HCFA-1490S
No
No
Form
HCFA-1490U
No
No
Federal Enterprise Architecture Business Reference Module
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:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
546,115,406
0
0
0
0
546,115,406
Annual IC Time Burden (Hours)
73,325,195
0
0
0
0
73,325,195
Annual IC Cost Burden (Dollars)
0
0
0
0
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.