Information Collection

Requests for Medicare Payment by Municipal Health Services Program (MHSP) Clinics

IC 112850 under ICR 199503-0938-001 · OMB 0938-0091.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Requests for Medicare Payment by Municipal Health Services Program (MHSP) Clinics

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-127				No	No
Form	HCFA-127A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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	443,000	443,000
Annual IC Time Burden (Hours)	70,880	70,880
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.