Information Collection

Evidence Of Coverage Under An Employer Group Health Plan

IC 157829 under ICR 199407-3220-003 · OMB 3220-0189.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0189 can be found here:

Documents and Forms

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Information Collection (IC) Details

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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

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 Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	100	100
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.