Information Collection

Incentive Arrangement Disclosure Form and Supporting Regulations -- 42 CFR 417.479, 417.500, 434.44, 434.70, 1003.100, 1003.101, 1003.103, and 1003.106

IC 8321 under ICR 199709-0938-011 · OMB 0938-0700.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0700 can be found here:

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Information Collection (IC) Details

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IC Title:	Incentive Arrangement Disclosure Form and Supporting Regulations -- 42 CFR 417.479, 417.500, 434.44, 434.70, 1003.100, 1003.101, 1003.103, and 1003.106	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-201				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	45,000	45,000
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.