Information Collection

Medicare, Information Collection Requirements In 405.2112, 405.2123, 405.2136, 405.2137, 405.2138, 405.2139, 405.2140, And 405.2171

IC 113628 under ICR 199410-0938-008 · OMB 0938-0386.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0386 can be found here:

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Information Collection (IC) Details

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IC Title:	MEDICARE, INFORMATION COLLECTION REQUIREMENTS IN 405.2112, 405.2123, 405.2136, 405.2137, 405.2138, 405.2139, 405.2140, AND 405.2171	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-52				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,321	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,321	321	2,000
Annual IC Time Burden (Hours)	87,094	78,094	9,000
Annual IC Cost Burden (Dollars)	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.