Information Collection

Health Insurance Common Claims Forms and Supportiing Regulations in 42 CFR 414.40, 424.32, and 424.44

IC 7757 under ICR 200005-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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:	Health Insurance Common Claims Forms and Supportiing Regulations in 42 CFR 414.40, 424.32, and 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: 1,321,417	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	717,876,097	22,707,767	695,168,330
Annual IC Time Burden (Hours)	44,460,460	359,798	44,100,662
Annual IC Cost Burden (Dollars)	0	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.