Information Collection

Competitive Medical Plan, Medicare Contract Application, Medicare Contract Application for Federally Qualified HMO and Supporting Regulations -- 42 CFR 417.408, 417.143

IC 8095 under ICR 199709-0938-001 · OMB 0938-0470.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0470 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Competitive Medical Plan, Medicare Contract Application, Medicare Contract Application for Federally Qualified HMO and Supporting Regulations -- 42 CFR 417.408, 417.143	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-901-2	Yes	Yes
Form	HCFA-901-1	Yes	Yes
Form	HCFA-901-3	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65	65
Annual IC Time Burden (Hours)	6,500	6,500
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.