Information Collection

Medicare/Medicaid Health Insurance Common Cliam Form, Instructions, and Supporting Regulations: 42 CFR 414.40, 424,32, 424.44

IC 7756 under ICR 199902-0938-008 · OMB 0938-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0008 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicare/Medicaid Health Insurance Common Cliam Form, Instructions, and Supporting Regulations: 42 CFR 414.40, 424,32, 424.44	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.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-1500	Yes	Yes
Form	HCFA-1490S	Yes	Yes
Form	HCFA-1490U	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 695,168,330	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	695,168,330	67,229,480	627,938,850
Annual IC Time Burden (Hours)	44,100,662	682,401	43,418,261
Annual IC Cost Burden (Dollars)	0	0	0

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