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Evidence Of Coverage Under An Employer Group Health Plan
EVIDENCE OF COVERAGE UNDER AN EMPLOYER GROUP HEALTH PLAN
OMB: 3220-0189
IC ID: 157829
OMB.report
RRB
OMB 3220-0189
ICR 199407-3220-003
IC 157829
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0189 can be found here:
1997-09-24 - Revision 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:
EVIDENCE OF COVERAGE UNDER AN EMPLOYER GROUP HEALTH PLAN
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
RL-311-F
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
300
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
600
0
600
0
0
0
Annual IC Time Burden (Hours)
100
0
100
0
0
0
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.