Information Collection Request

Payor Information Form

ICR 199904-1010-002 · OMB 1010-0033 · Historical Active

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IC IDCollectionTypeStatusForm
10668 Payor Information Form Form Migrated

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2002 06/30/2002 07/31/2000
23,000 0 23,000
17,250 0 19,167
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Payor Information Form MMS-4025

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 23,000 23,000 0 0 0 0
Annual Time Burden (Hours) 17,250 19,167 0 -1,917 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
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