Information Collection

Medicare Intermediary Request to Skilled Nursing Facilities for Medical Information on Claims to be Processed

IC 113163 under ICR 199504-0938-002 · OMB 0938-0223.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Medicare Intermediary Request to Skilled Nursing Facilities for Medical Information on Claims to be Processed

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-9031				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,536

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	111,925	111,925
Annual IC Time Burden (Hours)	55,963	55,963
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.