Information Collection

Medicare + Choice Provider-Sponsored Organization Waiver Request Form -- 42 CFR 422.370 through 422.378

IC 8381 under ICR 199807-0938-008 · OMB 0938-0722.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0722 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicare + Choice Provider-Sponsored Organization Waiver Request Form -- 42 CFR 422.370 through 422.378	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-231				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	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	30	30
Annual IC Time Burden (Hours)	300	300
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.