Information Collection

Medicare/medicaid Health Insurance Common Claim Form And Instructions

IC 112484 under ICR 199407-0938-002 · OMB 0938-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0008 can be found here:

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Information Collection (IC) Details

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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.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-1500	No	No
Form	HCFA-1490S	No	No
Form	HCFA-1490U	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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	546,115,406	546,115,406
Annual IC Time Burden (Hours)	73,325,195	73,325,195
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.