Information Collection

Request for Medicare Payment, Ambulance -- 42 CFR Section 410.40 and 424.124

IC 7796 under ICR 199902-0938-006 · OMB 0938-0042.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0042 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Request for Medicare Payment, Ambulance -- 42 CFR Section 410.40 and 424.124	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-1491				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,634,435	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 82 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,634,435	1,121,135	8,513,300
Annual IC Time Burden (Hours)	406,251	3,831	402,420
Annual IC Cost Burden (Dollars)	14,188,830,000	0	14,188,830,000

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.