Information Collection

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

IC 113811 under ICR 199407-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type

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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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-901-1	No	No
Form	901-3	No	No
Form	901-2	No	No

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

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.

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