Information Collection

Non-Federal Health Care Provider and Reimbursement Form

IC 147369 under ICR 199508-2900-006 · OMB 2900-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0160 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Non-Federal Health Care Provider and Reimbursement Form

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.	Available Electronically?	Can Be Submitted Electronically?
Form	10-1170	No	No
Form	10-5588	No	No
Form	10-2407	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,315

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	1,480	1,480
Annual IC Time Burden (Hours)	315	315
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.