Information Collection

Medicare/Medicaid Health Insurance Common Claim Form and Instructions -- 42 CFR 424.32 and 414.40

IC 7753 under ICR 199701-0938-005 · OMB 0938-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0008 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicare/Medicaid Health Insurance Common Claim Form and Instructions -- 42 CFR 424.32 and 414.40	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.	Available Electronically?	Can Be Submitted Electronically?
Form	L490S	Yes	Yes
Form	1490U	Yes	Yes
Form	HCFA-1500	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 76 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	644,802,423	644,802,423
Annual IC Time Burden (Hours)	46,797,008	46,797,008
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.