Information Collection

Notice of Preexisting Condition Exclusion

IC 13443 under ICR 199801-1210-001 · OMB 1210-0102.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0102 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Notice of Preexisting Condition Exclusion	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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: 6,590	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,372,840	1,282,370	90,470
Annual IC Time Burden (Hours)	8,150	6,915	1,235
Annual IC Cost Burden (Dollars)	700,000	625,000	75,000

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.