Information Collection

Notice of Pre-Existing Condition Exclusion

IC 13442 under ICR 199704-1210-003 · OMB 1210-0102.

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Documents and Forms

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Document Name	Document Type

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IC Title:

Notice of Pre-Existing Condition Exclusion

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

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

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,720

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	90,470	90,470
Annual IC Time Burden (Hours)	1,235	1,235
Annual IC Cost Burden (Dollars)	75,000	75,000

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.