Information Collection

Medicare/medicaid Health Insurance Common Claim Form And Instructions

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

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Document Name	Document Type

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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:

table that charts list of 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 %

table that charts list of burden
	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

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.