Information Collection

Certificate for Health Care Benefits

IC 12210 under ICR 199905-1115-007 · OMB 1115-0226.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Certificate for Health Care Benefits	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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14,000	14,000
Annual IC Time Burden (Hours)	25,620	25,620
Annual IC Cost Burden (Dollars)	2,100,000	2,100,000

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.