Information Collection

Limitation of Liability and Information Collection Requirements Referenced in 42 CFR 411.404(c)(2)+(3), 411.406(c)+(d)

IC 8085 under ICR 199710-0938-003 · OMB 0938-0465.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0465 can be found here:

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Information Collection (IC) Details

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IC Title:	Limitation of Liability and Information Collection Requirements Referenced in 42 CFR 411.404(c)(2)+(3), 411.406(c)+(d)	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-77				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 724,526	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,898,104	2,890,029	8,075
Annual IC Time Burden (Hours)	241,509	240,163	1,346
Annual IC Cost Burden (Dollars)	0	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.